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Full text of "U.S. Navy Medicine Volume 69, Number 1 January 1978"

VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADMR.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 



ASSISTANT EDITOR 
Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTREBUTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT R.D. Ulrey (DC); 
Education: CAPT S.J. Kreider (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak; Legal: LCDR R.E. Broach 
(J AGO; Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: CDR R.L. 
Surface (MSC); Naval Reserve: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT S.J. Kreider (MC); Research: CAPT 
J. P. Bloom (MC); Submarine Medicine: 
CAPT J.C. Rivera (MC) 

POLICY: VS. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed arc those of the authors and do 
not necessarily represent the official position of the Depart* 
mem of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command, 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202} 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35)« 



NAVMED P-508fl 



U.S.NAVY 




Volume 69, Number 1 
January 1978 



1 From the Surgeon General 

2 Department Rounds 

National Children's Dental Health Week: Operation brush-in . . 
The bitten bite back 

6 Policy 

Safe use of inhalation anesthetics in ambulatory care facilities . . 
Instructions and directives 

11 BUMED SITREP 

12 Notes and Announcements 

Dental continuing education courses . . . Nurse Corps continuing 
education courses approved . . . HSETC program directors . . . 
Medical school liaison officers needed . . . Abstracts sought in 
family practice 

14 Features 

Long Beach Alcohol Rehabilitation Service: A School for Living 
COL E.A. DeMar, USAFR, MC 

17 Medical Technology Assessment in the United States 
CDR T. McCarthy, MSC, USNR-R 

23 Professional 

Stomatitis Medicamentosa Associated with Gold Therapy for 
Rheumatoid Arthritis 
LTC. Mason, DC, USN 
CAPT R, Grisius, DC, USN 
CAPT T. McKean, DC, USN 

26 Outpatient Medical Records Audit 
CDR L.C. El/wood, MC, USN 



29 Scholars' Scuttlebutt 

Physical exam before ACDUTRA . . . Gl bill education 
ship student reimbursement claims 



Scholar- 



COVER: Navy dental activities are getting ready for National Children's 
Dental Health Week, set for 5-11 February. In 3 scene from last year's 
observance, CAPT John W.R. Anderson (DC), preventive dentistry offi- 
cer at Naval Regional Dental Center, San Francisco, examines a student 
from Treasure Island School, 



From the Surqeon General 



Setting the No Smoking Example 



WE IN THE medical profession are 
challenged today with a most per- 
plexing health problem. The strides 
of past generations in curtailing in- 
fectious disease and encouraging 
adequate nutrition and habitation 
have been securely reinforced into 
the fabric of our American public 
philosophy. Two major areas re- 
main, however, in our profession's 
fight against unnecessary disease 
and premature death. These areas 
are environmental pollution and 
self-destructive behavior. 

Self-destructive behavior takes 
many forms, including alcoholism, 
drug abuse, tobacco smoking, obe- 
sity, reckless driving, and suicide. 
One of the principal forms of self- 
destructive behavior among the pa- 
tients we care for is cigarette smok- 
ing. 

Today there can be no reasonable 
doubt that cigarette smoking is 
harmful and that the harm is done 
both to the smoker and to those ex- 
posed to the smoke. In fact, the 
World Health Organization has sug- 
gested that control of cigarette 
smoking alone could do more to im- 
prove health and prolong life in de- 
veloped countries than any other 
single action in the field of preven- 
tive medicine. 

As health care professionals, we 
must encourage programs which 
will decrease morbidity and early 
death— and that includes programs 
to decrease tobacco smoking. Our 
successful alcohol rehabilitation 
programs have highlighted several 
techniques that should prove 
equally applicable and successful in 
encouraging people to alter their 




CDR H.C. McKinney, CO of USS Sea- 
horse (SSN-669), explains operation of 
periscope to VADM Arentzen 

smoking habits. Some of these tech- 
niques are: 

• A meaningful physician-patient 
relationship. Just telling a patient— 
whether once or repeatedly— to stop 
smoking usually doesn't work. It 
takes time, involvement, and follow- 
up to help people alter their pat- 
terns of living. 

• Peer group experiences. Alco- 
holics Anonymous is the corner- 
stone of our alcohol rehabilitation 
program, and "stop smoking" 
groups show similar promise of 
success. 

• Identification with the healer. 
Physicians and other health profes- 
sionals should set an example by 



not smoking. Navy health care per- 
sonnel who smoke in front of their 
patients are derelict in their ethical 
duties to those patients. I strongly 
advise all Medical Department 
members who smoke to break the 
habit if they can, seek help if they 
cannot, but certainly to refrain from 
the purchase or use of cigarettes 
when around patients. 

Hospitals and clinics are health 
care delivery areas. It is ironic that 
cigarette smoking has traditionally 
been banned only around oxygen 
equipment. Since tobacco smoke it- 
self is hazardous, it should not be 
tolerated where patients— particu- 
larly patients with pulmonary dis- 
ease—are assembled. A no smoking 
policy should apply to passageways, 
waiting areas, physicians' offices, 
and any other spaces which are ven- 
tilated into patient care areas. 

The fight against infectious dis- 
eases is by no means over, but the 
principles of control have been 
generally accepted. That fight may 
seem easy when compared to the 
difficulties of combating self-de- 
structive behavior. But we cannot 
avoid the battle. As health care pro- 
viders, we must not only recognize 
tobacco smoking as harmful, but 
must also behave in a manner con- 
sistent with our knowledge that 
smoking is a health hazard. 



y^ 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 69, January 1978 



Department Rounds 



Dental Corps 



Operation Brush-In 



Last February the children of 
Navy families assigned to Parris 
Island, S.C., began displaying un- 
usual behavior: soon after lunch or 
after eating a snack, they would 
head for the restroom to brush their 
teeth. They also started bringing 
home posters they had made to tout 
the benefits of good oral health. 
And many of the youngsters took to 
checking up on their parents' dental 
care habits. 

The parents quickly got the word: 
It was National Children's Dental 
Health Week, and their children 
were in the thick of the Parris Island 
Naval Regional Dental Center's 
Operation Brush-In. 

This year again during National 
Children's Dental Health Week (5- 
11 February) Navy dental activities 
worldwide will sponsor dental edu- 
cation and treatment programs for 
children of Navy and Marine Corps 
members. So as not to interfere with 
the dental team's primary mission 
of serving active-duty personnel, 
these programs are usually con- 
ducted during off-duty time. 

Navy dental officers and dental 
technicians all stress that teeth are 
made to last a lifetime. Daily use of 
fluoride toothpaste is essential for 
keeping teeth and gums healthy, 
they tell the youngsters. So is 
cutting down on between-mea! 
sweets like candy bars and soda 
pop. 

National Children's Dental 
Health Week is sponsored each 
February by the American Dental 
Association. For the third consecu- 
tive year the theme of the week is 
"Smile, America." The goal: to 
awaken children and their parents 
to the importance of maintaining 
good oral health. 

During National Children's Den- 



tal Health Week last year, Navy 
dental activities carried out many 
successful projects. Here are high- 
lights of some of the best: 

• At Naval Regional Dental Center, 
Camp Pendleton, Calif., more than 
50 members of the dental health 
care team volunteered to give eligi- 
ble children preventive treatments 
and to participate in dental health 
education programs in the base 
school. Posters the school children 
made as part of the program were 
displayed around the base during 
February. 

• Sea World's Wonder Woman 
visited Naval Regional Dental Cen- 
ter, Orlando, Fla., giving their pro- 
gram a touch of show business 
glamour. Everyone pitched in for 
the week: members of the local 
Navy Wives Club joined some 140 
military and civilian dental workers 
to help launch a program of preven- 
tive dental treatment. Beneficiaries 
of this assistance included Seminole 
County Migrant Health Project par- 
ticipants. 

• Staff members of Naval Regional 
Dental Center, Norfolk, Va., worked 
with members of the local #206 
Dental Reserve Unit to provide pro- 
grams for dependents of shore- 
based and fleet-based personnel. 
Special National Children's Dental 
Health Week messages were 
printed on shopping bags and milk 
cartons used on the military base. 

• A "Happy Tooth" puppet show 
for primary school children and 
audiovisual aids for the upper 
grades helped the staff of U.S. 
Naval Regional Dental Center, 
Subic Bay spread the dental health 
message in the Philippine Islands. 
Through the local THETA (teenage 
health education teaching assist- 
ants) Program, specially trained 




4 £ ^ 



Child gets fluoride treatment in Guam 




Annapolis kids practice brushing 



high-school students discussed 
good dental care with small groups 
of youngsters. More than 1,000 stu- 
dents toured the Cubi Branch Den- 
tal Clinic, where they received a 
dental screening examination, oral 
hygiene instruction, and a topical 
fluoride application. A mass media 
campaign also gave support: the 
local newspaper carried a series of 
preventive dentistry feature arti- 
cles, radio and television stations 
carried spot announcements, and a 
five-minute television interview 
with a dental officer was aired sev- 
eral times. Also, the Navy Ex- 
changes designed special window 
displays for National Children's 
Dental Health Week. 



U.S. Navy Medicine 




Youngsters at Norfolk receive check-ups and learn how to use dental floss as part oi a preventive dentistry program 




Wonder Woman from Sea World visits Naval Regional Dental Center Orlando 

Volume 69, January 1978 



Instructor teaches oral hygie 



Preventive Medicine 



The Bitten Bite Back 



They were here when Jean 
Ribault landed in 1562. They have 
survived the island's humid climate 
for more than 400 years and when 
the first Marines arrived at Parris 
Island, the "Flying Teeth" were 
there to greet them. Today they still 
swarm to new arrivals at the Marine 
Corps Recruit Depot, Parris Island, 
S.C. 

Sandflies or "culicoides," pests 
near and dear to the hearts of all 
Parris Island personnel, fly under 
many names: biting midges, biting 
gnats, sand fleas, no-see-ums. It all 
depends upon what part of the 
country you happen to be visiting. 

The U.S. Navy and U.S. Depart- 
ment of Agriculture have combined 
forces to conduct an intensive re- 
search project focused on these 
pests. 

The Preventive Medicine Service 
at the Parris Island hospital annex 
takes the initial steps in the re- 
search project by collecting sam- 
ples. The USDA Research Labora- 
tory in Gainesville, Fla., then uses 
these samples for further studies 
and classification. 

The project began when LT 
James R. McCormick (MSC), depot 
preventive medicine officer and 
environmental health officer, col- 
lected data on patients with celluli- 
tis from July 1975 through March 
1976. 

"The insect (sandfly) bite was 
directly responsible for the majority 
of all cellulitis infection of exposed 
skin areas," LT McCormick re- 
ported. "These insect bites are not 
only painful, but also itch a long 
time after the bite. Usually, pro- 
longed scratching follows, which in- 
advertently opens the skin; invad- 
ing bacteria then introduce subsur- 
face inflammations known as acute 
cellulitis infection." 

LT McCormick played a major 
role in initiating the research project 
and is responsible for planning and 
coordinating all local activities. He 



first contacted the Disease Vector 
Ecology and Control Center in Jack- 
sonville to ask for help combating 
the sandfly problem. The research 
laboratory in Gainesville was then 
contacted. The result: a research 
project funded by the Naval Facili- 
ties Engineering Command, Atlan- 
tic in Norfolk through the Depart- 
ment of Defense Armed Forces Pest 
Control Board. 

Over the next 10 months, logisti- 
cal planning established the long- 
term, joint USN/USDA sandfly re- 
search project. 

Disease carriers. The research 
project became a reality in January 
1977 when USN/USDA program 
representatives briefed key man- 
agers at the recruit depot and Naval 
Hospital Beaufort, S.C, on the 
project's objectives. 

For ecological diversity there are 
three testing areas: the major one at 
Parris Island, another at Fort 
Myers, Fla., and a third at Yankee- 
town, Fla. 

In the past no sustained research 
had been done on sandflies because 
they were not known to be disease 




Dr. Kline (L) and HMC Wilson remove 
sandfly container from emergency trap 




LT McCormick (L) and HMC Wilson 
check light trap for captured sandflies 



4 




HMC Wilson collects mud samples and specimens to identity sandflies 



U.S. Navy Medicine 



carriers in the U.S. However, sand- 
flies have been directly associated 
with numerous diseases of men and 
animals in the Caribbean and else- 
where, and there is potential for this 
type of problem here. 

In phase 1 of the project — biologi- 
cal study of the sandfly — most of 
the on-site research is done by 
HMC Leonard Wilson, a preventive 
medicine technician and vector con- 
trol specialist. Chief Wilson was as- 
signed to the USDA Gainesville 
office last April for recertification as 
a vector control specialist. While 
there, he studied advanced tech- 
niques for collecting and identifying 
insects. His special interest: sand- 
flies. 

Once a month, Dan L. Kline, 
Ph.D., a research scientist with the 
Gainesville laboratory, visits the 
Parris Island recruit depot to ob- 
serve the project's progress, coordi- 
nate activities with the preventive 
medicine officer, and obtain sam- 
ples for further studies. 

Life cycle. Sandflies are so small 
that 12 to 16 of them, placed end to 
end, might equal one inch. There 
are three major species on Parris 
Island: Culicoides hollensis, Culi- 
coides furens, and Culicoides mel- 
leus. 

The life cycle of culicoides con- 
sists of four stages: egg, larvae, 
pupae, and adult. Eggs are tiny and 
difficult to find. They are laid on the 
mud or sand near pieces of debris or 
in small depressions. 

In the larval stage sandflies re- 
semble worms but are still barely 
large enough to be seen. During 
their larval and pupal stages, sand- 
flies are found either in the mud of 
salt marshes or in intertidal sand. 

The body of adult sandflies con- 
sists of three regions: head, thorax, 
and abdomen. On the head are a 
pair of compound eyes, antennae, 
and mouthparts. The antennae of 
the male appear to be hairy. Female 
mouthparts are adapted for blood- 
sucking, while males feed on plant 
juices. Sandfly wings may be plain 
or marked with a pattern of light 
spots against a darker background. 
Wing pattern is an extremely im- 



portant identification characteristic. 
Chief Wilson is responsible for 
the initial steps of the biological 
studies carried out in a temporary 
field laboratory. Collection traps, 
some of which are modified mos- 
quito traps, are placed in various 
locations around the depot. As the 
sandfly completes its life cycle and 
becomes an adult, it emerges from 
the salt marsh mud. The cone- 
shaped trap often covers a breeding 
site, and as the sandflies rise from 
the mud to the surface, they travel 
through the cone to reach the light 
above, where they are captured. 
These traps enable researchers to 
identify sandfly breeding sites. 



Studies of sandfly biology will 
permit researchers to predict more 
accurately regional infestation 
peaks; preventive medicine special- 
ists will then be able to develop a 
thorough pest management system 
and make better use of current vec- 
tor control techniques. 

In the future, researchers will be 
seeking more effective measures of 
control by refining existing insecti- 
cides and developing new ones — 
particularly insecticides containing 
chemicals already approved for use 
to protect man and his environment. 

Future research will involve labo- 
ratory and field studies with larvi- 
cides for long-range control, and 




Dr. Kline (L) confers with HMC Wilson on culicoides identification 



Attack peaks. Seasonal and daily 
attack times vary with the different 
sandfly species. Culicoides hollensis 
has two peaks of abundance: one in 
the spring and another in the fall. 
Most of their activity occurs during 
the day. Culicoides/Hrems is present 
from late April to early October. 
There are several peaks of abun- 
dance, the largest occurring in late 
May, August, and September. 
Furens are active at night, with bit- 
ing peaks at sunrise and sunset. 
Culicoides melleus appears in early 
April and remains on the scene until 
the end of September. Like furens, 
melleus is active at night. 



adulticide evaluations with aerial 
and ground equipment to develop 
immediate remedial control meas- 
ures. Researchers will also investi- 
gate various biological controls, 
growth regulators, toxicants, para- 
sites, predators, and pathogens in 
disease transfers known to be asso- 
ciated with sandflies. 

The researchers also hope to de- 
velop repellents that can assure 
protection for extended periods. But 
the ultimate goal is to bring the 
sandfly population at Parris Island 
down to a safe, tolerable level. 

— Story and photos by LCPL Cheryl A. 

Cooke. 



Volume 69, January 1978 



Policy 



Safety Tips 



Safe Use of Inhalation Anesthetics in 
Ambulatory Care Facilities 



CDR John P. Swope, MC, USN 
BUMED, Code 416 



National Fire Prevention Association (NFPA) stand- 
ard 56G, "Inhalational Anesthetics in Ambulatory Care 
Facilities," was developed to guide outpatient facilities 
where general anesthesia is administered or relative 
analgesia produced. This standard is, in essence, a 
companion document to NFPA 56A, "Inhalational 
Anesthetics," described in U.S. Navy Medicine in July 
1977. 

NFPA 56G provides safety requirements to protect 
against fire, electrical shock, and mechanical injury 
from compressed gases or compressed gas cylinders in 
a surgical setting. Protection is also provided against 
anoxia from erroneous gas connections without unduly 
limiting the activity of the practitioner, whether 
surgeon, oral surgeon, dental anesthesiologist, or 
anesthesiologist. Safety requirements for the manufac- 
ture, storage, transportation, and handling of gas cylin- 
ders before their delivery are not covered by this stand- 
ard. 

Hazards can be eliminated or minimized if physical 
safeguards are established and if staff members of 
ambulatory care facilities pay meticulous attention to 
maintaining safe practices. Studies of hazards associ- 
ated with hospital operating rooms over a period of 30 
years saw that the greatest safety is secured only 
through a completely coordinated program, not by in- 
stituting individual or unrelated safeguards. Therefore, 
all personnel dealing with anesthetic agents are re- 
quired to work together in this precautionary program. 
AH such personnel should have thorough, current 
knowledge of the hazards posed by electrical shock, use 
of compressed gases, and fire in an oxygen-enriched 
atmosphere. In addition, it is essential that they update 
their knowledge regularly through continuing educa- 
tion. 

NFPA S6G is divided into four parts: 

1) Introductory material, including definitions of 
terms used throughout the standard and in the enforce- 
ment of requirements established by the standard. 

2) Discussion of hazards of fire, electrical shock, and 



use of compressed gas. 

3) Standards for installing and testing medical gas 
systems. 

4} Requirements for administration and maintenance 
of ambulatory care facilities. 

There are also four appendices which give additional 
information and explain the rationale behind the stand- 
ard's requirements. A complete text of NFPA 56F, 
"Nonflammable Medical Gas Systems," is an addi- 
tional appendix. 

NFPA 56G cites NFPA 70, "National Electrical 
Code," and its applicable requirements. Other stand- 
ards referenced are NFPA 56A, "Inhalational Anes- 
thetics"; NFPA 56B, "Respiratory Therapy"; and 
NFPA 56F, "Nonflammable Medical Gas Systems." 
AH these standards have been reviewed in previous 
issues of U.S. Navy Medicine. 

NATURE OF HAZARDS 

Combustion. In NFPA 56G, the discourse on the 
nature of hazards emphasizes that oxygen and nitrous 
oxide, normally used for relative analgesia and as com- 
ponents of general anesthesia, are strong oxidizing 
gases; individually or in combination, they readily sup- 
port combustion. Where oxygen and nitrous oxide are 
used, materials flammable and combustible in air ignite 
more easily and burn more vigorously. Thus, many 
materials commonly found around patients — hair oils, 
oil-based lubricants, skin lotions, clothing, linen, 
paper, rubber, alcohols, and plastics, for example — 
may become major fuels. 

The three requirements for fire or combustion are 
fuel, supporting material (such as oxygen or nitrous 
oxide), and a source of ignition, such as an open flame, 
burning tobacco, heating coils, defective electrical 
equipment, or adiabatic heating of gases. (This latter 
effect occurs when sudden compression or recompres- 
sion of a gas to high pressure generates increases in 
temperature up to 2,000° F.; such temperature ex- 



6 



U.S. Navy Medicine 



tremes can easily ignite organic materials.) 

Toxicology. NFPA 56G contains a cautioning note for 
toxicologic hazards: when modern, nonflammable in- 
halational anesthetic agents are used with high-flow 
techniques, and when there is inadequate ventilation of 
excess gases, the atmosphere may produce low-grade 
toxicity in people who regularly work in the facility. 

Further, if plastic materials catch fire, highly toxic 
products of combustion may cause sudden unconscious- 
ness, cardiovascular collapse, and severe injury or 
death, even in people relatively remote from the fire. 
These products of combustion have caused injury after 
passing through halls, ventilation systems, and even an 
electrical conduit. 

Mechanical injury, Since gas cylinders contain a 
large amount of energy, they should be handled care- 
fully. If the valve of the cylinder should break off, the 
cylinder's contents may be discharged with sufficient 
force to cause the cylinder to spin wildly or move uncon- 
trollably through the force of jet propulsion. 

NFPA 56G describes in detail hazards of transferring 
the contents of one compressed gas cylinder into 
another. Recompression of gas without dissipation of 
heat generated by the adiabatic process can cause com- 
bustible materials to ignite. 

ELECTRICAL HAZARDS 



stalled and tested according to NFPA 56F, the standard 
for nonflammable medical gas systems. If portable sys- 
tems are used and are the sole supply of nitrous oxide 
and oxygen, NFPA 56F recommends that two cylinders 
of each gas be attached to the administrating device to 
provide a reserve supply. Electrical circuits shall be 
equipped with grounding contacts. 

Anesthetic apparatus shall be subject to approval by 
the authority having jurisdiction.* Between the appara- 
tus and the flush-type cylinder valves commonly used 
with anesthetic gas cylinders there shall be a yoke-type 
connection, #860, as described in ANSI [American 
National Standards Institute] B57.1 of 196S, "Com- 
pressed Gas Cylinder Valve Outlet and Inlet Connec- 
tions." If adjustments or repairs involving the use of 
tools are done on the equipment, the gas anesthesia 
apparatus shall be tested before it is used again on pa- 
tients. Also, the final common path machine outlet to 
the patient shall be tested to determine that only 
oxygen is delivered from the oxygen flow meters and 
oxygen flush valve. Interventions requiring such 
testing shall include but not be limited to alteration of 
pipelines, hoses or fittings; alteration of internal 
piping; adjustment of selector switches or flush valves; 
and replacement or repair of flow meters or bobbins. 

MAINTENANCE OF EQUIPMENT 



The main electrical hazard of concern to personnel 
working with inhalation anesthetics is electric shock 
resulting from a failure in normally safe electrical sys- 
tems or appliances. The problem may result from de- 
fective wiring, faulty components, deteriorated insula- 
tion, or mechanical abuse. Electric shock in turn may 
cause unde sired muscle contraction, with injury to the 
person administering the anesthetic, the patient, or in 
surgical procedures, the operating physician. The prob- 
lem is further complicated because patients under 
anesthetic do not feel pain and therefore lose their 
normal protective reflex response to electric shock. 
Electric shock may also cause cardiac disturbance, 
leading to ventricular fibrillation and death. 

The electrical energy supplied by a defective system 
may cause serious burns. Also, sparking and arcing 
caused by a defective electrical system may serve as an 
ignition source for combustion. 

NFPA 56G also addresses the problem of electrical 
fibrillation of the heart in patients whose cardiac pace- 
makers have external conductors. If stray electrical 
currents in the range of millionths of an ampere (micro- 
amperes) contact one of these conductors, ventricular 
fibrillation may occur. However, patients with external 
pacemakers normally are not treated in ambulatory 
care facilities. 

EQUIPMENT 

Central gas supply systems, when used, shall be in- 
Volume 69, January 1978 



The administration and maintenance section of 
NFPA 56G is an adjunct to physical precautions spe- 
cified in the section on equipment; again, the hazards 
involved in the use of anesthetic agents can only be 
minimized when recognized by all personnel. Responsi- 
bility for physical protection rests with everyone in- 
volved in the functioning of anesthetizing locations. 

Special precautions include the safe handling of 
oxygen cylinders, proper functioning of manifolds, and 
proper maintenance of cylinder storage facilities. The 
physical safeguards built into the anesthetizing location 
or storage area will not provide protection unless safe 
work practices are followed and good maintenance is 
provided. Scheduled inspections should be carried out 
and defective electrical equipment properly replaced or 
repaired. Rules and regulations for the functioning of 
ambulatory care facilities should be posted. Appendix 
C of this standard gives a suggested text to be posted. 

As the trends toward outpatient surgery and toward 
frequent use of anesthesia as an adjunct to dental prac- 
tice grow, NFPA 56G will become increasingly impor- 
tant. This pamphlet should be held by all Navy health 
care facilities. 



*The phrase "authority having jurisdiction" is commonly used in 
NFPA documents. The NFPA itself does not make all decisions re- 
garding enforcement of NFPA standards; such decisions are made by 
the office or agency that implements the standard, whether it be the 
fire inspector, the Joint Commission on the Accreditation of Hospi- 
tals, or the hospital administrator. 



Instructions and 
Directives 



Equal Opportunity Program 

Phase I of the Navy Equal Opportunity Program pro- 
vided a minimum of 18 hours of race relations education 
to increase awareness of prejudice and discrimination 
within the Navy. 

Implementation of Phase II is now required for all 
BUMED-managed activities. BUMED schedules Phase 
II implementation on a regional basis and provides 
activities with help from two BUMED equal opportunity 
program specialist teams. Before Phase II is imple- 
mented, demographic data must be collected on the 
rank/rate, sex, race, ethnic group and individual work 
unit of command personnel. Also, all commanding offi- 
cers and officers-in-charge are required to submit an 
affirmative action plan to BUMED (Code 008) for ap- 
proval. 

The following elements are considered minimum 
requirements of Phase II implementation: 

• Counter Racism/Equal Opportunity Workshop (for 
selected command personnel) 

• Women in the Navy Workshop (for E-6 and above) 

• Action to Counter Racism Workshop (E-6 and above) 

• Military Rights and Responsibilities Workshop (E-5 
and below) 

• Cultural Expression in the Navy Workshop (all 
hands) 

• Affirmative Action Plan Workshop (selected com- 
mand personnel) 

• Command Training Team (selected E-7 through E-9 
and 0-3 and above) 

• Command Data Bank 

• Human Relations Council 

Quarterly, all commands except those completing 
Phase II will report the status of Phase II to BUMED 
(Code 008).— BUMED Instruction 1500. 12B of 11 July 
1977. 

Anthropometric Compatibility Assignment 
Program 

A system of anthropometric measurements and cod- 
ing has been developed to identify aircrew personnel 
whose size is compatible with today's cockpits. 
BUMED Code 51 is responsible for implementing and 
managing this program, and for coordinating with 
Chief of Naval Operations, Commandant of the Marine 
Corps, Bureau of Naval Personnel, and Naval Air Sys- 
tems Command. 

The commanding officer of the Naval Aerospace 
Medical Institute shall ensure that the following meas- 



urements are obtained for all aviation candidates dur- 
ing their initial physical examination: sitting height, 
functional reach, buttock-knee length, and buttock-leg 
length. These measurements shall be converted to a 
four-digit code and recorded on the Anthropometric 
Data Record (BUMED 6410/9). A copy of this record 
will be sent to the Naval Aerospace Medical Research 
Laboratory. 

The commanding officer of Naval Aerospace Medical 
Research Laboratory shall ensure that this data is in- 
corporated into the Human Factors Data Bank, and 
shall provide a weekly report for the naval aviation 
schools command. Biweekly reports of Marine Corps 
members will be sent to the Marine Aviation Training 
Support Group. 

Fleet aviation personnel with potential cockpit an- 
thropometric incompatibilities shall be referred to the 
nearest aviation physiology training unit to be meas- 
ured. If such measurement reveals an incompatibility, 
this information shall be recorded in the member's 
health record, using NAVMED 6410/9, and provided to 
the commanding officer and other involved personnel 
as required. If cockpit reassignment is sought, official 
command correspondence shall be sent to the Chief of 
Naval Personnel or the Commandant of the Marine 
Corps, via Chief, BUMED and the appropriate chain of 
command. 

All anthropometric measurements recorded before 1 
Jan 1977 are invalid for the purpose of this instruction. 
—BUMED Instruction 3710.1 of 11 July 1977. 

Measles (rubeola) immunization 

Use of live attenuated measles virus vaccine, intro- 
duced in the U.S. in 1963, has reduced the number of 
affected patients to approximately 35,000 a year. There 
has also been a reduction in the incidence of post- 
measles encephalitis, and in other major complications 
of the disease. 

However, large local outbreaks of rubeola continue to 
occur, and recent surveys indicate that some 35% of 
American children between 1 and 4 years of age have 
never been immunized against the disease. 

Live attenuated measles virus vaccine is available to 
Navy medical treatment facilities and should be offered 
beneficiaries in accordance with American Academy of 
Pediatrics recommendations. Generally, measles im- 
munization should be delayed until the child is 15 
months old, but during a measles outbreak the vaccine 
may be given any time at or after 6 months, and should 
be followed by a second inoculation when the child is 15 
months old. Nonimmunized infants who will be travel- 
ing outside CONUS may be immunized after the age of 
6 months, with reimmunization after they are 15 
months old. Also, all children who have been im- 
munized with live attenuated measles vaccine before 
the age of 12 months should be reimmunized at or after 
the age of 15 months. 



U.S. Navy Medicine 



Adults ordinarily need not be immunized against 
measles since most have prior immunity. However, 
vaccination of adults may be considered for isolated 
groups of people who have no prior immunity. 

Because live virus measles vaccine may temporarily 
depress tuberculin skin sensitivity, tuberculin testing 
should be scheduled before the vaccine is administered. 
During measles outbreaks, requirements for prior 
tuberculin testing may be waived. Children already 
under treatment for tuberculosis may be immunized 
with live virus measles vaccine; however, the effect of 
the vaccine on children with untreated tuberculosis is 
unknown. 

Large outbreaks of rubeola among Navy health care 
beneficiaries should be reported. 

[Note: CAPT D.F. Hoeffler (MC), director of the Oc- 
cupational and Preventive Medicine Division at 
BUMED, reports that Navy children may be somewhat 
better off than the general public. In a survey of fami- 
lies seen at one naval regional medical center, 78% of 
children age 5 years and younger had been immunized 
against measles. However, Dr. Hoeffler points out that 
the survey did not address 6-14-year-old boys and girls 
who are especially important immunization targets. 
Measles is now being seen in sporadic epidemics 
among older children and adolescents, Dr. Hoeffler 
says. 

A reminder: The goal of the National Immunization 
Initiative called for by President Carter is complete im- 
munization of all children age 14 and under. Ed.] — BU- 
MED Instruction 6230. 12B of 18 July 1977. 

Radiation workers 

Individuals working for or being considered for Navy 
work as occupational radiation workers and who are 
medically qualified in all respects except for a history of 
therapeutic irradiation for a benign condition, may be 
employed in work involving possible exposure to ioniz- 
ing radiation pending review of their medical history by 
BUMED. However, people who have been treated with 
therapeutic irradiation for other than a benign 
condition shall not be employed as occupational radia- 
tion workers until their medical history has been re- 
viewed by BUMED and approval obtained for their 
employment. 

[Note: The Radiation Effects Advisory Board will also 
request reports of slit lamp examination and thyroid 
scan in patients who have a history of therapeutic irra- 
diation to the head or neck. Ed.]— BUMED Notice 6470 
of 19 July 1977. 



Weight standards 

Since change 91 to the Manual of the Medical De- 
partment was issued, there has been some confusion 
about weight tables. The tables in MANMED arts. 15- 
17 and 15-27 (change 91) apply to applicants for enlist- 



ment, appointment, or commission in the Navy and 
Marine Corps. BUPERS Instruction 6110.2B with 
change 1 and MANMED art. 15-51 provide weight con- 
trol maintenance guidelines for active-duty Navy and 
Marine Corps members. — BUMED Notice 6110 of 25 
July 1977. 



Preventive medicine annual report 

The semiannual report of preventive medicine activi- 
ties (MED 6200-1) has been changed to an annual re- 
port. — BUMED Instruction 6200.9D, change transmit- 
tal 1, of 28 July 1977. 



Medical Reserve Policy Advisory Board 

A Medical Reserve Policy Advisory Board has been 
established to represent inactive Reserve components 
of the Medical Department and to advise the Surgeon 
General on inactive Naval Reserve programs. 

Board chairman is the Reserve Medical Inspector 
General. Members are all inactive Reserve Medical 
Corps flag officers, representatives of the 16 Naval Re- 
serve readiness command staff medical officers, the 
Fourth Marine Division surgeon, Fourth Marine Air 
Wing medical officer, Reserve Construction Forces 
Brigade medical officer, Reserve liaison directors for 
the Medical Service Corps and nursing services, master 
chief petty officer liaison for the medical program, and 
the director of the Naval Reserve Division, BUMED. 

The Board will meet at least once a year. — BUMED 
Instruction 6000.7 of 1 Aug 1977. 



Standard food service disinfectant 

The standard military disinfectant commonly used in 
Navy food services is temporarily unavailable. A sub- 
stitute commercial disinfectant is now available under 
stock number NSN 6840-01-035-5432. 

The substitute product will be used until the standard 
disinfectant is again in stock. However, since the 
substitute product is not designed for military use, 
special directions must be followed to ensure it is ac- 
ceptable for use in the field. 

To disinfect mess gear, the disinfectant should be 
dissolved in 25 gallons of rinse water. The substitute 
disinfectant cannot be used in water colder than 50° F. 

Fresh fruits and vegetables should be left whole and 
unpeeled, and washed in a solution made by dissolving 
a package of disinfectant in 20 gallons of 100° F. water. 
After they are washed, fruits and vegetables should be 
immersed for 30 minutes in a similar but freshly pre- 
pared solution. Disinfectant solutions should not be re- 
used; a fresh solution should be prepared for each use. 
After 30 minutes, fruits and vegetables should be re- 
moved from the solution and rinsed thoroughly in 
potable water.— BUMED Notice 6240 of 4 Aug 1977. 



Volume 69, January 1978 



9 



Military veterinary medical support 

Military veterinary medical support for Navy and 
Marine Corps activities is authorized on a nonreim- 
bursable basis. Veterinary personnel are trained in food 
establishment sanitation and may be used to inspect 
commissary stores. Inspection and reporting proce- 
dures will be coordinated between the environmental 
health officer and the senior veterinary support person 
at the inspection site. 

Veterinary personnel should be used primarily to 
perform sanitary inspections of food processing estab- 
lishments and facilities; inspect food supplies to deter- 
mine conformance with contractual requirements; 
determine that perishable items are properly stored, 
handled, and transported; investigate animal diseases, 
particularly diseases transmissible between animals 
and man; and provide veterinary medical and surgical 
services for Government-owned animals. 

Activities requiring veterinary support shall submit a 
request to CHBUMED (Code 55) via the Navy Food Ser- 
vice Systems Office or the Commandant of the Marine 
Corps. Requests for veterinary research personnel shall 
be sent to CHBUMED (Code 55) via the Naval Medical 
Research and Development Command. 

An Interservice Support Agreement (DD Form 1144) 
shall be executed between the activity requesting sup- 
port and the Army or Air Force activity providing 
veterinary personnel. — BUMED Instruction 6401. IB of 
8 Aug 1977. 

Revision of dental classification 

Change 91 to the Manual of the Medical Department 
(article 6-101) contained significant modifications to 
dental classification criteria and to the color coding sys- 
tem used for dental folders. Dental commands, ser- 
vices, and departments should introduce these new 
criteria during FY78. 

The revised criteria, together with the newly intro- 
duced requirement for all active-duty personnel to 
undergo annual oral examinations, will undoubtedly 
cause a change in the number of people in various clas- 
sification categories. Dental officers should ensure that 
local Line commanding officers understand that cate- 
gory increases may be due to modified examination 
methods and revised classification criteria. — BUMED 
Note 6620 of 16 Aug 1977. 

Hospital Corps A School 

Minor changes have been made in eligibility require- 
ments for admission to Class A Basic Hospital Corps 
School. Candidates must now earn a combined Word 
Knowledge (WK) and Arithmetic Reasoning (AR) score 
of 105 on the Armed Services Vocational Aptitude Bat- 
tery. Formerly, this test was called the Basic Test Bat- 
tery, and requirements were for a combined general 
classification test (GCT) and arithmetic (ARI) score of 
105. 



Also, candidates with a history of drug abuse will be 
carefully screened to ensure they are good risks for 
Hospital Corps School.— BUMED Instruction 1510. 11F 

of 17 Aug 1977. 

New food service inspection form 

Beginning December 1977, a new four-part form, 
NAVMED 6240/1, Food Service Sanitation Inspection, 
will be available in the supply system under stock num- 
ber 0105-LF-206-2400. The new form is to be used for 
inspection of Navy food service facilities ashore and 
afloat, and will improve the inspection program by 
standardizing inspection and reporting procedures. 

Along with the new form, a point scoring system is 
being introduced establishing minimum scores for 
passing sanitation inspections and correcting defects. — 
BUMED Notice 6240 of 6 Sept 1977. 

Armed forces regional health services system 

Effective 1 Oct 1977, the 13 medical regions of the 
Armed Forces Regional Health Services System have 
been realigned into nine regions. Navy medical facili- 
ties should establish local liaison with Army and Air 
Force counterparts within their region. — BUMED 
Notice 5450 of 15 Sept 1977. 

Dental inspections 

This notice sets forth a tentative schedule through 
September 1978 for command inspections by the In- 
spector General, Dental. Activities will be contacted 
approximately two months in advance of a planned 
inspection concerning more specific dates. — BUMED 
Notice 5040 of 13 Oct 1977. 

Aeromedical Safety Officer Program 

A number of flight surgeon, aviation physiologist, 
and aviation experimental psychologist billets have 
been identified and assigned to the Aeromedical Safety 
Officer (AMSO) Program to assure continued direct 
aeromedical safety support to Navy and Marine Corps 
aviation establishments. 

Aeromedical safety officers will provide specialized 
consultation, advice, and recommendations in aero- 
medical aspects of safety, training, and operation of 
Navy and Marine Corps aviation. Specific duties will 
include: participation in local aviation safety programs; 
monitoring of local aviation life support systems; par- 
ticipation on relevant boards and committees, and in 
readiness evaluation of aviation units; evaluation of 
aeromedical aspects of local search and rescue plans; 
liaison with environmental health and preventive medi- 
cine services, as well as with the local naval regional 
medical centers; and coordination of epidemiological 
approaches to accident trends and causes. — BUMED 
Instruction 5100.11 of 14 Oct 1977. 



10 



U.S. Navy Medicine 



BUMED SITREP 



ASBESTOS SAFETY ... The Navy is 
conducting studies at Pearl Harbor and 
Long Beach Naval Shipyards to deter- 
mine the extent and effect of possible 
asbestos exposure on shipyard workers. 
Plans are being made to extend these 
studies to other naval shipyards. 

An intensive audit of all Navy ship- 
yards also is being conducted to ensure 
that safety procedures previously estab- 
lished for handling asbestos materials 
are being followed. During ship repair 
and overhaul, rigid protective measures 
are prescribed to prevent workers' ex- 
posure to asbestos. In addition, the 
Navy prohibits ripping out asbestos at 
sea, except in emergencies. Rip-out in 
port is conducted under the same re- 
strictions applicable to shipyard civilian 
personnel. Workers in occupations with 
a high risk of exposure to asbestos 
fibers are examined when First hired 
and annually thereafter. Also, these 
workers receive a complete medical 
examination upon termination of em- 
ployment. 

In a related development, the Chief of 
Naval Operations established an asbes- 
tos policy task group on 16 Aug 1977 to 
develop a comprehensive Navy policy 
on asbestos, including medical surveil- 
lance, environmental monitoring, and 
establishing Navy responsibility and 
obligation to former employees. Current 
Navy directives will be revised as neces- 
sary to reflect expanded responsibili- 
ties. Even under the present guidelines, 
the occupational medicine community 
will be significantly tasked, since in- 
creasing numbers of asbestos workers 
and other shipyard production workers 
now require physical examinations. 

HEARING CONSERVATION ... BU- 
MED expects to revise its Hearing Con- 
servation Program instruction to con- 
form to an anticipated Department of 
Defense instruction. From preliminary 
indications, DOD hearing conservation 
efforts appear to be moving toward a re- 
quirement that hearing protection be 
worn by all personnel routinely exposed 
to noise greater than 85 dBA, without 
regard to duration of exposure. The re- 
vamped program will also include re- 
quirements for audiometry to detect 
early onset of hearing loss and a de- 
tailed disposition scheme for individuals 
so detected. While engineering control 



of noise remains the preferred method, 
appropriate combinations of hearing 
protection and engineering control will 
be allowable in situations where noise 
levels are not routinely greater than 100 
dBA. The revised program will also in- 
clude preselection criteria to ensure that 
personnel with preexisting hearing 
losses cannot be assigned to noise haz- 
ardous areas or in noise hazardous job 
classifications. 

BL'MHl) continues to improve audi- 
ometric support, with initiatives in 
baseline audiometry for recruits, mobile 
audiometric vans to support afloat units 
at pierside, and improved training of 
audiometric technicians. Automated 
audiometry and a central data registry 
are also being explored. 

MICROWAVE OVEN SURVEY ... BU- 
MED and the Food and Drug Adminis- 
tration's Bureau of Radiological Health 
(BRH) have negotiated a memorandum 
of understanding regarding the Micro- 
wave Oven Survey Program. Under the 
terms of the agreement, BRH will cali- 
brate specific microwave oven survey 
instruments and perform minor repairs 
on the instruments. Through official 
notice, BUMED will promulgate dates 
of calibration and details regarding the 
calibration service; survey instruments 
are to be sent to BRH only during the 
periods identified in this notice. 

BRH will also provide forms for col- 
lecting microwave oven survey data, 



and will periodically forward several re- 
lated reports to BUMED. Survey reports 
are not to be used until a change to BU- 
MED Instruction 6470.16 is promul- 
gated. The proposed change will include 
specific instructions on the conduct, 
documentation, and reporting require- 
ments of a microwave oven survey. 

Navy liaison office for the Microwave 
Oven Survey Program is Undersea 
Medicine Division (BUMED, Code 
5321). 

FLIGHT SURGEON MANUAL ... The 

revised edition of the U.S. Naval Flight 
Surgeon 's Manual will be distributed to 
all naval flight surgeons at their official 
duty stations this month. Flight sur- 
geons who want the manual to be 
mailed to a different address should in- 
form the Commanding Officer (Code 
00S), Naval Aerospace Medical Insti- 
tute, NAS Pensacola, Fla. 32508. People 
who require the manual but are not 
flight surgeons should also address 
their request to NAMI. 

TAX RELIEF ... An amendment to 
Public Law 95-171 exempts all Armed 
Forces Health Professions Scholarship 
Program students from income tax with- 
holding on stipend, tuition, fees, and 
other educational expenses paid by the 
government. This tax exemption is ret- 
roactive to 1 Jan 1977. It will remain in 
effect until 31 Dec 1982 for all students 
who enter the program before 1 Jan 
1979. Students who enter the program 
on or after 1 Jan 1979 will not be 
covered by this law. 




NRDC ORLANDO . . . This new 27-chair naval regional dental center opened 
11 Aug 1977 in Orlando, Fla. Under the command of CAPT Harry C. Pund, 
Jr. (DC), the new center will provide dental care for staff members of Naval 
Training Center, Orlando, for its three component commands and 23 tenant 
activities, and for other active-duty members in the central Florida area. 



Volume 69, January 1978 



11 



Notes & Announcements 



DENTAL CONTINUING EDUCATION COURSES 

The following dental continuing education courses 
will be offered in April 1978: 

National Naval Dental Center, Bethesda, Md. 

Occlusion 3-5 April 1978 

Dental materials 17-19 April 1978 



Eleventh Naval District, San Diego, 
Oral surgery 
Preventive dentistry 



Calif. 

3-7 April 1978 
24-26 April 1978 



U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 

Oral diagnosis and therapeutics 17-20 April 1978 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: 
Commanding Officer, Naval Health Sciences Education 
and Training Command (Code 5), National Naval Medi- 
cal Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

Cross-country travel and travel from outside the con- 
tinental U.S. to attend dental continuing education 
courses generally will not be approved due to funding 
limitations. 

NURSE CORPS CONTINUING EDUCATION 
COURSES APPROVED 

The quarterly meeting of the Nurse Corps Continuing 
Education Approval and Recognition Program (CEARP) 
review board convened in October 1977 at the Naval 
Health Sciences Education and Training Command, 
Bethesda, Md. The following 36 continuing education 
programs were approved for the contact hours 
indicated in parentheses: 

NNMC Bethesda, Md. 

Theories and Techniques of Crisis Intervention for Nurses (2.5) 

NRMC Bremerton, Wash. 

Budget Preparation for Continuing Education and Inservice Divi- 
sions (2) 
The Adult Learner— How Do We Meet the Needs? (2) 

NRMC Great Lakes. III. 
Depression (1) 

Hypertensive Management (1) 
Basic Life Support (6) 
Audit Series for Beginners (6) 
Sex and the Heart Patient (1) 

NSMC Groton, Conn. 

Introduction to Nursing Care of Patients Needing Hyperbaric Ther- 
apy (2) 



The Abused Child: Nursing Responsibilities (2) 

The Process and Implementation of Performance-Evaluation for 
Nursing Service Personnel (2) 

Nursing Care of Patients in Traction (2) 

Nursing Care of Patients with Inflammatory Bowel Disease (2) 

Construction of Relevant Nursing Care Plans for Hospitalized Pa- 
tient (2) 

Nursing Care of Patient Undergoing Radical Head and Neck Sur- 
gery (2) 

Intensive Care Nursing Course (30) 

NRMC Jacksonville, Fla. 
Hyperalimentation (2) 
Budget and Supplies (2) 
Child Abuse (2) 
Radical Neck Surgery and Tracheostomy Care (2) 

NRMC New Orleans, La. 

High Risk Pregnancy/High Risk Newborn (7) 

Psychosocial Aspects of Aging (4.6) 

The Process of Aging — A Multidisciplinary Approach (6) 

NRMC Newport, R.I. 
Using Maternal Bonding as Conceptual Framework for Develop- 
ment of Family-Centered Maternity Unit (Category II) (4) 

Newborn Assessment (1.5) 
Maternal Infant Bonding (1) 

NRMC Orlando, Fla. 

Changing Concepts in Cardiology and Their Effects on Nursing 
Practice (1.5) 
Cardiopulmonary Resuscitation (6) 

NARMC Pensacola, Fla. 

Cardiopulmonary Resuscitation Basic Rescuer's Course (6) 

NH Whidbey Island, Oak Harbor. Wash. 
Child Abuse Today (3) 
Child Growth and Development (3) 
Obstetrical Emergencies (3) 
Current Concepts in Orthopedic Nursing (3) 
Fluid and Electrolytes (3) 
Acid-Base Balance and Blood Gases (3) 

U.S. NRMC Yokosvka. Japan 
Communications Workshop (7.5) 

Nurse Corps officers interested in attending one of 
these courses should request a quota from the host 
command. 

Accreditation of the Navy Nurse Corps CEARP by the 
Northeast Regional Accrediting Committee of the 
American Nurses Association precludes retroactive ap- 
proval of offerings. Programs should be submitted for 
review 30 days before the date they will be offered. 

HSETC PROGRAM DIRECTORS 

Questions often arise concerning education and train- 
ing, and no one locally may have the answer. The 
following is a list of directors at the Naval Health 
Sciences Education and Training Command who will 
provide professional and technical advice on continuing 
education programs. 



12 



U.S. Navy Medicine 



Code 4: Medical Corps Programs and Clinical Investigations 
Programs 

CDR C.T. Cloutier, MC, USN 
Autovon: 295-0584 

Code S: Dental Corps Programs and Dental Technician Programs 
CAPT J.B. Holcomb, DC, USN 
Autovon: 295-0650 

Code 6t Medical Service Corps Programs 
LT J.A. Kramer, MSC, USN 
Autovon: 295-0624 

Code 7; Nurse Corps Programs 

CAPT P.A. Butler, NC, USN 
Autovon: 295-0630 

Code 8: Hospital Corps Programs 

LCDR R.E. Newman, MSC, USN 
Autovon: 295-1524 

Code 9: Subsidy Programs 

LT W.M. Oals, Jr., MSC, USN 
Autovon: 295-0218 

Questions pertaining to available education pro- 
grams should be sent to: Commanding Officer, Code , 

Naval Health Sciences Education and Training Com- 
mand, National Naval Medical Center, Bethesda, Md. 
20014, or phone appropriate number. 

MEDICAL SCHOOL LIAISON OFFICERS NEEDED 

The Medical Department is looking for Reserve phy- 
sicians who wish to assume new responsibilities as 
medical school liaison officers. Originally appointed to 
recruit and indoctrinate medical students, MSLOs now 
assist in physician recruiting as well. Specifically, they 
are being asked to invite active-duty Navy physicians 
into their schools and civilian medical groups to present 
professional papers, participate on panels, and in other 
ways show the civilian medical community the high 
quality of Navy medicine. 

Reserve medical officers are still needed to fill MSLO 
positions at many medical schools. Interested officers 
are urged to request appointment through their region- 
al Reserve readiness commanders. 

MSLOs are needed at the following schools: 

RedCom 1 

Boston U School of Medicine 

Harvard Medical School 

U of Connecticut School of Medicine 

Yale U School of Medicine 

RedCom 2 

Albert Einstein College of Medicine of Yeshiva U 
Columbia University College of Physicians and Surgeons 
Mount Sinai School of Medicine of the City of New York 
New York U School of Medicine, N.Y.C. 
U of Rochester School of Medicine and Dentistry 
State U of New York at Buffalo School of Medicine 
State U of New York at Stony Brook 

State U of New York Upstate Medical Center College of Medicine, 
Syracuse 

RedCom 4 

The Hahnemann Medical College of Philadelphia 



RedCom 5 

The U of Pittsburgh School of Medicine 

Medical College of Ohio at Toledo 

Wright State U School of Medicine, Dayton, Ohio 

RedCom 6 

The George Washington U School of Medicine and Health Sciences 

U of Maryland School of Medicine 

West Virginia U School of Medicine 

RedCom 7 

Duke U School of Medicine 

RedCom 8 

Emory U School of Medicine 

RedCom 9 

U of South Alabama College of Medicine 

RedCom 10 

U of Texas Medical Branch at Galveston School of Medicine 

RedCom 11 

U of New Mexico School of Medicine 

RedCom 13 

Wayne State U School of Medicine 

Southern Illinois U School of Medicine 

U of Illinois College of Medicine 

Rush Medical College of Rush University 

Medical College of Wisconsin, Milwaukee 

Michigan State Osteopathic Medical School 

Chicago College of Osteopathy 

RedCom 16 

U of Minnesota Duluth School of Medicine 
U of North Dakota School of Medicine 
Des Moines Osteopathic Medical College 

RedCom IS 

Creighton U School of Medicine 
U of Missouri at Kansas City 
Washington U, St. Louis 

RedCom 19 

Loma Linda U School of Medicine 

Others 

U of Hawaii School of Medicine 

U of Puerto Rico School of Medicine 



ABSTRACTS SOUGHT IN FAMILY PRACTICE 

The Clinical Investigation Committee, Uniformed 
Services Chapter, American Academy of Family Physi- 
cians, is seeking papers for its April 1978 meeting in 
Jacksonville, Fla, Honorariums will be given. 

Papers will be selected on the basis of originality, 
appropriateness to family practice research, and depth 
of statistical analysis. Prospective studies are encour- 
aged. Format will be 10 minutes per presentation, fol- 
lowed by 10 minutes for discussion. 

Selection will be made by the Clinical Investigation 
Committee, in conjunction with the Scientific Assembly 
Program chairman. Submit abstracts to: MAJ Harry H. 
Rinehart (MC), Box 859, MAMC, Tacoma, Wash. 
98431. 



Volume 69, January 1978 



13 



Features 



Long Beach Alcohol Rehabilitation 
Service: A School for Living 



COL Edgar A. DeMar, USAFR, MC 



Last year, I spent two weeks as a 
visiting physician on the Alcohol 
Rehabilitation Service of NRMC 
Long Beach, Calif. As a Reserve Air 
Force flight surgeon, I was included 
in a group of 15 health care profes- 
sionals — mostly Navy physicians, 
nurses and chaplains — whose train- 
ing was guided by the unit's direc- 
tor, CAPT Joseph Pursch, MC, 
USN. We were there to receive 
orientation and instruction in the 
problem of alcoholism; we hoped to 
gain greater understanding of this 
illness and thereby to be better 
prepared to help alcoholics. What 
actually happened was that each of 
us during those two weeks came to 
understand that rehabilitation 
means helping alcoholic patients 
reach new insights about them- 
selves, so they can then help them- 
selves begin new lives. 

What was so outstanding and dif- 
ferent about our two-week experi- 
ence? Why did we all — patients, 
staff, families, and visiting physi- 
cians — feel so much was accom- 
plished? I should point out that 
most of the patients who arrive at 
the Long Beach Alcohol Rehabilita- 
tion Service do not think they have 
any problem with alcohol: it's only 
after the training begins that the 
patients — and even a few visiting 
physicians — discover that yes, they 
do have a problem. 

In a way, what happens at Long 
Beach is fairly simple. It starts with 

COL DeMar is a flight surgeon for United 
Air Lines, San Francisco International Air- 
port, San Francisco, Calif. 94128, and wing 
surgeon of the 349th MAW (Assoc.) (AF 
Res), Military Airlift Command, Travis AFB. 
Calif. 



an accepting attitude, which means 
that your mind is ready to work with 
and accept new ideas, that your 
body is physically present in the 
training sessions, not hurrying to 
outside activities, and that you are 
personally and totally involved, not 
a spectator looking in through a 
window. Such participation, of 
course, is the antithesis of the 
"don't get involved" or "I'm going 
to stay out of that" philosophy. It 
seems to me that, be the subject 
alcoholism, religion, business, law, 
or any other endeavor, to achieve 
true success and gratification you 
must get totally involved and be- 
lieve in what you are doing. This we 
did at Long Beach. 

NO HIDING BEHIND TITLES 

We had all heard about the Long 
Beach Alcohol Rehabilitation Ser- 
vice and were attracted to it because 
jof its reputation. Now, for the first 
time, we were going to see the ARS 
in operation and be a working part 
of it. 

As a part of continuing medical 
education, I had already attended 
many lectures on alcoholism and 
seen educational films about the 
problem. They were interesting, but 
I had not been touched personally 
and there had been no close patient 
contact. So I felt a certain thrill ar- 
riving on the hospital ward that first 
day, reporting for duty but not 
knowing exactly what to expect. It 
didn't take long to find out. 

We were involved immediately. 
In a short indoctrination lecture, we 
were told we would spend most of 
our time on the ward with patients. 



We would be on a first name basis 
with everyone. There would be no 
hiding behind rank, title, or closed 
doors; there would be no long ab- 
sences during the day. 

Dr. Pursch quickly pointed out 
that alcoholism is a chronic, pro- 
gressive, relapsing disease which 
may be fatal, but which can be con- 
trolled at any time by intervention 
and rehabilitation. No one individ- 
ual can treat the alcoholic, he said; a 
team approach is necessary and 
continuous follow-up by a peer sys- 
tem like Alcoholics Anonymous as 
well as by interested and trained 
health care personnel is essential. 

Dr. Pursch stressed that alco- 
holics are people who have tried to 
solve their living problems with 
alcohol, and have failed. 

Alcoholism can (and eventually 
will) cause problems in any part of a 
person's life — mental, physical, 
family, financial, work, or with 
social contacts. I was surprised to 
learn that many alcoholics do not 
really want to drink. Some have 
never enjoyed alcohol, but it has 
become an uncontrollable compul- 
sion, just like overeating or gam- 
bling is for other people. The alco- 
holic needs help: he cannot resolve 
his problems alone. In fact, he and 
his family will often deny that any 
problem exists. 

We also learned that, in general, 
health care deliverers have done a 
poor job of creating a favorable at- 
mosphere in which the alcoholic can 
begin his recovery, or in eradicating 
alcoholism — now the third largest 
health care problem in our country. 
(It is surpassed only by cardiovascu- 
lar disease and cancer.) 



14 



U.S. Navy Medicine 



While learning about alcoholism, 
we began to learn a lot about our- 
selves. For example, some of us had 
been avoiding alcoholic patients for 
one reason or another, perhaps be- 
cause we could not get a 100% cure 
every time. Some of us were dis- 
couraged by our belief that alco- 
holics never change and always 
end up drinking again. But as our 
awareness of the alcohol disease 
problem grew, we learned that it 
can be successfully treated in up to 
90% of patients. And we ourselves 
saw people "change" during our 
short stay in Long Beach, and met 
speakers, therapists, and alumni 
who had been abstinent, sober, and 
successful for 20 to 30 years. 



drinking after he leaves the hos- 
pital. To help with this phase of 
rehabilitation, we met daily in small 
encounter groups of eight to ten 
people under the guidance of a 
counselor who was, in most cases, a 
recovered alcoholic. 

DIRECT AND SINCERE 

Group therapy is used extensively 
in alcoholic rehabilitation programs. 
It helps establish communication, 
freeing participants to discuss and 
evaluate long-blocked thoughts and 
emotions. So frequently in our lives 
the simple job of communicating is 
stymied. Group therapy provides a 
natural outlet. 




Civilian psychologist, Vivian Gary, Ph.D., conducts assertiveness training for par- 
ticipants in Long Beach Alcohol Rehabilitation Service 



In the ARS, alcohol drinking 
ended quickly. Within three to five 
days, most patients were free of the 
acute effects of alcohol withdrawal. 
Resolving the deeper problems 
behind acute alcoholism became the 
real challenge. These problems had 
to be brought to the conscious mind 
where they could be discussed, 
evaluated, and resolved; if this 
important work is not done, the pa- 
tient will almost certainly resume 



We began to learn about each 
other by speaking directly and sin- 
cerely, and always on a first-name 
basis. We tried to be ourselves, 
stripped of our facade and defenses. 
We spoke with understanding for 
the other member's problems, 
treating all participants with respect 
and dignity, and careful to use the 
first person singular "I think," 
rather than the impersonal "one 
thinks." 



Upon arrival in a group, each new 
member briefly described his per- 
sonal life, telling why he came to 
the ARS, what his drinking habits 
were, and what he thought about 
them. We visitors were no exception 
to this rule. 

Since we met in groups for more 
than an hour each day, it became 
very difficult not to get involved in 
conversations with others, even 
though some people took several 
days to start describing their deeper 
thoughts and feelings. By freely dis- 
cussing problems of different mem- 
bers of the group, we soon recog- 
nized that we alt have problems in 
our lives, and that it helped to dis- 
cuss them. In the process, we all 
learned the meaning of humility. 
We came to realize that our own 
mental defenses were often very 
similar to those used by the pa- 
tients: the defenses differed in 
quantity rather than type. 

COURSE OF ALCOHOLISM 

Although alcoholics may deterio- 
rate in different ways, they end up 
at the same discouraging place. 
Alcohol becomes the center of the 
alcoholic's life, affecting his whole 
being. He has no control over it. 
Blackout periods may last for hours, 
even days. In a blackout the alco- 
holic may drive an automobile, hold 
up a bank, treat patients, or carry 
on conversations about important 
matters — but he will not remember 
any of this later. The final disposi- 
tion of the alcoholic will be the hos- 
pital, jail, or death. 

But this dismal outcome can be 
avoided if recovery from alcoholism 
takes place. Recovery begins when 
someone recognizes the alcoholic's 
problem, confronts him with it, and 
somehow gets him into rehabilita- 
tion. After some initial resentment, 
the alcoholic usually accepts help 
and begins his recovery. 

At NRMC Long Beach, patients 
respond well to treatment for alco- 
holism and have a high recovery 
rate. It is difficult to define just 
what factors influence this transfor- 
mation. There are many good reha- 



Volume 69, January 1978 



15 



bilitation centers in both military 
and civilian environments, but what 
distinguishes the Long Beach pro- 
gram is an outstanding attitude of 
concern for the patient demon- 
strated by the entire staff. Their 
only objective is to help the alcoholic 
patient recover and to give him a 
fresh start on a new life. 

I sensed this spirit of concerned 
cooperation in doctors, nurses, 
counselors, corpsmen, and clerks. It 
certainly eased the patients' task of 
learning about their disease and 
adjusting their mind and body to do 
without alcohol. 

At Long Beach, a controlled 
environment is necessary for the 
first two weeks of rehabilitation. 
During this time patients are re- 
stricted from overnight passes and 
leave. This restriction helps reduce 
the opportunity for exercising bad 
judgment during the early phases of 
learning about alcoholism, and 
helps the patients adjust to a more 
normal way of life. 

Families are encouraged to attend 
lectures and group therapy, since 
they are so deeply involved in the 
effects of alcoholism. As the patient 
learns to talk about his problem and 
gains insight into it, he can discuss 
his condition with his family and 
new-found friends. His attitude to- 
ward his disease often changes so 
completely that he becomes inter- 
ested in helping others with the 
same problem — an ambition that 
can be satisfied individually as well 
as through the fellowship of AA. 

It is a misconception that the der- 
elict comprises the majority of alco- 
holics. At the ARS, patients come 
from all walks of life — physicians, 
nurses, chaplains, attorneys, pilots, 
mechanics, and many other voca- 
tions. No group is immune. These 
are the people who live next door, 
who work and socialize with you, or 
with whom you practice medicine. 

For fortunate recovering alcohol- 
ics, rehabilitation means a fresh 
start. But important as rehabilita- 
tion is, it is worthless without con- 
tinuous follow-up care provided by 
an interested, concerned person or 
peer group. The recovering alco- 



holic thus uses "people support" 
rather than drugs to overcome 
periods of anxiety or depression 
which may occur, especially during 
the first two or three years after 
rehabilitation. This support of 
friends, AA, or church associations 
rescues the person from solitude — 
one of the worst forms. of punish- 
ment, in or out of confinement. 

WHAT CAN WE DO? 

Like the Biblical prodigal son, the 
alcoholic is hurting and in pain. He 
will change only when he finds 
himself, when others no longer 
cover for him or lie for him and 
thereby help him get sicker. To that 
end, nonalcoholic people need to 
understand alcoholism so they can 
provide the only real help: pushing 
the alcoholic into rehabilitation. 

If alcoholism is a disease, it 
follows that health care profes- 
sionals should take a leading part in 
obtaining proper care and rehabili- 
tation for alcoholics. First, health 
care personnel must recognize the 
disease, even when the patient or 
his family denies its presence. Alco- 
holism has an insidious onset, with 
varying signs and symptoms, and 
can cause problems for as lor^g as 13 
years before some major incident 
confirms the diagnosis. With addic- 
tion to alcohol, the compulsion to 
continue drinking is great. 

It is a waste of time to look for an 
alcoholic; physicians should look in- 
stead for signs and symptoms of 
alcoholism. Alcohol may cause 
tremors, insomnia, blackouts, or 
hallucinations. Frequent injuries, 
bruises, gastritis, pancreatitis, hep- 
atitis, and bleeding abnormalities 
must all be suspected as having 
their origin in alcohol abuse. Tachy- 
cardia, hypertension, flushing, and 
agitation may be present. Also in- 
dicative of alcoholism are family 
problems, poor work records, old 
rib fractures, or frequent fights. 

Liver function tests and blood 
studies revealing anemia and high 
blood alcohol levels are a few of the 
laboratory tests which help physi- 
cians make the diagnosis. 



When the diagnosis of alcoholism 
is confirmed, the physician must 
confront the alcoholic with the 
findings and inform him of the de- 
structive course of the disease. 
Ideally, it is best to make this con- 
frontation in the presence of the pa- 
tient's family, friends, or employer. 
Asking their help involves these 
significant people in the patient's 
recovery and increases his chances 
for success. 




ARS training includes group discussions 

Responsibility for his behavior 
must remain with the alcoholic. If 
and when the alcoholic accepts 
treatment, the physician must not 
only be aware of treatment centers 
in the community (or elsewhere), 
but must also arrange a consultation 
for the patient or admission to a 
hospital if necessary. If the physi- 
cian does not make this extra effort, 
the patient seldom will. 

Not every report in the ARS files 
is a success story. But enough pa- 
tients do recover from the devas- 
tating effects of alcohol abuse, 
achieve sobriety, and return to 
productive service to make the 
Navy's investment in the program 
worthwhile. It remains for all health 
care personnel to educate them- 
selves about the effects, signs, and 
symptoms of alcoholism, and with 
compassionate concern to support 
the alcoholic on his journey to recov- 
ery. 



16 



U.S. Navy Medicine 



Medical Technology Assessment 
in the United States 



CDR Thomas McCarthy, MSC, USNR-R 



The literature on the impact of medical technology on 
specific diseases has been extensive in the U.S. during 
the past decade. However, only during the past three or 
four years have studies focusing on practical applica- 
tions concerned with assessing the relative costs and 
societal benefits that accrue from new technologies be- 
come prominent. This development stems largely from 
a somewhat belated realization among governmental 
and private-sector officials that available resources, 
even in a country as affluent as the U.S., are indeed 
limited, and that expenditures for health care amount- 
ing to close to 9% of the gross national product may be 
approaching the upper limit that our society will accept. 

Research by institutional and industrial organizations 
and academic centers on assessment of medical tech- 
nology, however, is still in its formative stages. We do 
not have any clear understanding of either the proc- 
esses of technological diffusion or the full range of the 
effects and impacts of technology. So the challenge of 
constructing theories and methods of assessment has 
led to multifaceted activity by many groups, including 
the U.S. Congress and several agencies of the Execu- 
tive Branch of the federal government, as well as uni- 
versities, the business community, and professional 
health groups. Let me illustrate this pluralistic attack 
by identifying some federal government organizations 
active in this field. 

The Office of Technology Assessment, for example, 
in existence for only three years, was established by the 
U.S. Congress to conduct short-term policy research 
designed to identify alternative approaches to technol- 
ogy-related issues in many areas, including health, and 
to provide objective analysis of the probable cost/bene- 
fit consequences of choices among those alternatives. 

In the Executive Branch of government, the National 
Science Foundation participates in projects to evaluate 
the longer- range societal impact of technological de- 
velopment, including development of health care tech- 
nology. 

Within the Department of Health, Education, and 
Welfare (HEW), the National Institutes of Health, and 
especially the National Cancer Institute and the Nation- 
Thomas McCarthy, Ph.D., is associate administrator for health 
systems liaison, Health Resources Administration, Dept of Health, 
Education and Welfare, Washington, D.C. 20782, 

This paper was presented at the Symposium on Assessment and 
Containment of Medical Technology, Katholieke Universiteit Leuven, 
Belgium, 16 Nov 1977. 



al Heart and Lung Institute, are exploring possibilities 
of requiring cost/efficacy assessments of all technologi- 
cal developments as they may affect health services 
that emerge from biomedical research programs sup- 
ported by the institutes. 

Of course, considering pharmaceutical agents as 
technological products, the longest established and 
most pervasive technology assessment program in the 
U.S. is conducted by the Food and Drug Administration 
of HEW. This agency regulates — with the power of 
severe federal sanctions, fines, and jail sentences — 
introduction of new pharmaceutical agents and medical 
devices into general medical practice. Policies are 
based on the efficacy of the product, its safety, and ab- 
sence of fraud in its production and distribution. 

So far I've mentioned government agencies primarily 
involved in assessing the efficacy of new technological 
developments and their introduction into the main- 
stream of medical practice. What about existing, avail- 
able technologies? Here, with the concept of assess- 
ment broadened to embrace some estimates of the 
amount or quantity of a technological capacity needed 
to meet the health care service requirements of a popu- 
lation, agencies responsible for paying the costs of utili- 
zation of technology come into play. 

The newly established Health Care Financing 
Administration within HEW is involved in examining 
the cost/benefits of applications of existing technol- 
ogies. Under 1972 legislation establishing professional 
standards review organizations, for example, this 
agency is setting up a nationwide network of groups of 
local physicians who review the appropriateness of care 
provided by their peers, including use of costly forms of 
technological intervention and unduly elaborate facili- 
ties provided patients whose care costs are reimbursed 
from federal sources. 

The Health Resources Administration — the HEW 
agency with which I am associated — is establishing 
state and regional health planning mechanisms, with 
one function of these planning agencies being to match 
the supply of available technologies with health care 
service needs. Under the National Health Planning 
Resources and Development Act of 1974, for example, 
my agency is setting up a "certificate of need" pro- 
gram which requires evidence that investments in new 
medical facilities or equipment in each state and local 
health services area are justified on the basis of inade- 
quate existing service capacity to meet the require- 



Volume 69, January 1978 



17 



merits of the population residing in those areas. Cur- 
rently, 29 states have such certificate- of-need laws; 
another 39 states have signed agreements with HEW to 
participate in a process of review prior to approval of 
capital expenditures for health purposes. 

At the federal level, the Bureau of Health Planning 
and Resources Development — a part of my agency — 
issues guidelines that state and local planning agencies 
use in their review and approval of new facilities and 
technology; the Bureau also provides technical assist- 
ance to these agencies both directly and indirectly 
through document and publication services and support 
of planning, research, and training centers. 

Beyond the federal government level, state and local 
governments, which also pay for health care services, 
can exert direct control over introduction of new tech- 
nologies or use of existing technologies — but they 
rarely do. Likewise, agencies and institutions in the 
voluntary and private sectors also can play important 
roles. For example, the National Blue Cross Association 
and the Blue Shield Plans, and other so-called "third- 
party payers" or insurance carriers, frequently re- 
examine existing (and new) technologies to determine 
whether to cover associated utilization charges in their 
insurance benefits. For example, the Association of 
Blue Shield Plans is just completing a study of existing 
surgical procedures to determine the extent to which 
these procedures may be outmoded or redundant. 

The Institute of Medicine of the National Academy of 
Sciences, an independent organization chartered by 
Congress many years ago, is an important private re- 
source for technology assessment research. I'll refer to 
one of its studies later. 

ASSESSMENT RESEARCH 

What are the results of all this activity? As you know, 
the U.S. health care system is anything but monolithic 
in its organization. No one private organization or 
governmental unit controls all or even significant por- 
tions of the system's functions. Consequently, no one 
governmental unit or private sector organization can 
take sole or overall responsibility for addressing broad 
policy issues — such as assessment of existing health 
practice technologies — with any expectation that it can 
totally control implementation of the results of its ef- 
forts. This is part of the American political system of 
checks and balances. Decisions about the use of health 
technology assessment in the U.S. must have a diverse 
and pluralistic base. Under our current arrangements, 
successfully coping with problems of medical technol- 
ogy utilization depends upon the consent of many dis- 
parate agencies and organizations. 

This leads me to the First point I want to emphasize in 
these remarks: research in health services — in this in- 
stance, medical technology assessment — must be the 
major factor in providing the foundation for accommo- 
dating competing interests in arriving at sound deci- 



sions about technology investments. 

Before discussing some general areas of concern in 
health technology assessment research, I would like to 
review recent initiatives taken by HEW's National 
Center for Health Services Research, which I helped set 
up and where I served as its first deputy director until 
assuming my current position. The National Center, in 
its formative stages some 10 years ago, recognized that 
health care technology should be one important and 
integral area of its work. At that time, we attempted to 
structure a national research policy to address what ap- 
peared to us to be an important evolving issue: cost- 
effective technology. I can say in retrospect that we 
have been disappointed in the results to date. Not that 
we haven't produced some interesting assessments and 
plans, but that the issues simply are more complex than 
we appreciated, and we were probably trying to push 
solutions rather than to formulate more critical 
questions. 

A number of studies, however, have been completed 
over the years which specifically relate to the larger 
social and economic impact of medical technology. 
These include evaluation of high-cost health care for 
end- stage kidney disease, identification of the incen- 
tives and decision processes underlying hospitals' 
adoption and utilization of major capital equipment, 
and quality of performance in terms of costs and bene- 
fits of automated diagnosis and multiphasic screening. 

I would like to discuss briefly one recently completed 
study conducted in Boston. Six specific pieces of costly 
medical equipment were evaluated in terms of costs 
and benefits to patients cared for in 15 area hospitals. 
The items evaluated were: cardiac catheter laborato- 
ries, automated diagnostic X-ray machines, computers, 
automated blood analyzers, patient monitors, and auto- 
mated laboratory washing machines. 

The results of this study indicated that much of the 
equipment's capacity was unused. In the 15 hospitals, 
utilization rates of 50% to 60% of capacity were found 
for autoanalyzers, diagnostic X-ray machines, and pa- 
tient monitors. The study also found that hospital 
decision-makers did not seem to employ systematic, 
quantitative methods for evaluating the costs and bene- 
fits of prospective equipment purchases. 

Furthermore, for this sample of hospitals the direct 
contribution of such hospital equipment expenditures 
was about 9 % of the total per diem cost inflation over 
the period examined. These data suggest that the cost 
of complementary inputs, such as additional staff, may 
be more important in explaining cost inflation than 
direct expenditures on the equipment itself! Much of 
the equipment studied also exhibited a rapid rate of 
technological obsolescence, with the expected life of 
some equipment only five to eight years. 

Not surprisingly, this study also suggests that the 
proportion of hospitals adopting new and costly tech- 
nologies in the U.S. is related to the ability of an area to 
pay for services. This is inferred from the positive rela- 



18 



U.S. Navy Medicine 



tionship between the level of adoption and the extent of 
third-party insurance coverages, per capita income, 
and philanthropy. In a sense, advanced technology fol- 
lows the availability of money. 

The National Center early on also sponsored various 
studies assessing applications of computer technology, 
especially as it relates to consolidated hospital systems 
where automated medical records and billing are fre- 
quently managed through a centralized system. Over- 
all, results emerging from these studies suggest that 
such systems offer several advantages: 

• reduced clerical and personnel costs, 

• reduced lost charges and rejected claims. 

• increased cash flow. 

• improved professional communication and continuity 
of care. 

• improved patient record availability. 
The disadvantages seem to be: 

• a potential for invasion of privacy. 

• increased annoyance to professionals who are re- 
quired to structure their inputs to the system. 

• increased technical costs, especially in the develop- 
mental phase. 

Two areas in which medical technology assessment 
has come under particular scrutiny in the U.S. are its 
application to rural health care and to long-term care 
and catastrophic illness. 

As you know, areas of low population density present 
special problems with respect to provision of health 
services. Mobile units to provide part-time clinic 
services are being widely employed in dispersed areas 
and now are being assessed more carefully in such 
areas with respect to their utility. The most elaborate 
mobile facility unit yet developed in the U.S. was pro- 
vided under a project which attempted to utilize appli- 
cations from costly space technology in providing rural 
health care on the Papago Indian Reservation near 
Tucson, Ariz. This mobile unit has two examining 
rooms; X-ray, laboratory and pharmacy facilities; so- 
phisticated telecommunications; a computer-based 
medical record system; and a self-contained electrical 
generator. 

The results of this and similar units, as determined 
from studies sponsored by the National Center, suggest 
that although mobile units can provide services to pa- 
tients who have inadequate transportation, reduce in- 
vestments in duplicative equipment and supplies, and 
command substantial resale value, they have severe 
disadvantages. Specific disadvantages are: high oper- 
ating costs, loss of service time while the unit is in 
transit, and loss of privacy, with associated noise prob- 
lems. Final assessment, however, remains to be made. 

Another highly questionable application for rural 
areas involves telecommunication technology. Evalua- 
tion of findings from National Center studies suggests 
that the advantages lie in reduced patient travel time 
and inconvenience, an enhanced attractiveness of 
remote sites to physicians, and better conditions for 



patient services. However, disadvantages are increased 
costs (especially for long-distance telephone and televi- 
sion systems), inconvenience associated with telecon- 
sultation, and inadequate telephone services in rural 
areas to support the system. 

Turning now to long-term care and catastrophic 
illness, we are all aware of the so-called "aging" of the 
population, not only in the U.S., but in most western 
societies. The health care needs of the elderly are as- 
suming a higher priority, as is a new effort in the U.S. 
to protect people against catastrophic economic effects 
of extended or highly complex and rare illnesses. 

Use of costly life-sustaining technologies for long- 
term care and chronically ill persons recently came into 
national prominence in the U.S. because of Karen 
Quinlan. The parents of this 20-year-old girl presented 
and won a State Supreme Court case which allowed 
them to take their comatose daughter off a life-sustain- 
ing respirator against the objections of the hospital 
staff, after the medical community had agreed that she 
could never be restored to an independent life. As a 
result of this and similar cases, the public is increas- 
ingly questioning why it should pay for technology to 
support life when the costs are excessive and the pa- 
tient's chances for a normal, productive, or satisfying 
life are practically nil. There has been a somewhat 
bizarre, but socially instructive twist to the Quinlan 
story: when the "plug was pulled" on the equipment 
believed to be the only means of sustaining the pa- 
tient's life, she did not die; to this day she lives, al- 
though in a deep coma and with no awareness. One 
truly must pause and reflect on the limits of our empiri- 
cal knowledge, particularly when making life or death 
decisions. 

In this instance, the benefit assessment problem in- 
volves deep and profound moral and ethical questions 
which, in a normative sense, can be addressed by prop- 
erly designed research. 

The ethical and social issues involved in achieving 
equity in access to and use of services when the service 
at question involves very costly equipment, procedures 
and manpower, and when the incidence of the illness is 
small relative to the whole population, were the subject 
of a 1973 study by the National Academy of Sciences 
Institute of Medicine. The study was prompted by 
national legislation authorizing public payment for 
renal dialysis and kidney transplants for end-stage 
renal disease. The basic question addressed was, If, for 
whatever reasons — cost, limited capacity, location — a 
service cannot be provided to everyone, every place, on 
what basis should selective access be made available? 
The Academy recommended against public coverage of 
health care costs in a disease-by-disease approach, and 
identified the kinds of studies that should be conducted 
before additional diseases were covered. 

The possibility of a totally implantable artificial heart 
loomed large in the Academy's deliberations. A com- 
panion study on that development, conducted by the 



Volume 69, January 1978 



19 



Hastings, N.Y., Institute of Society Ethics and the Life 
Sciences, proposed the view, not unanimously held by 
all participants in the deliberations, that the only equit- 
able solution seemed to be a random selection in the 
form of a lottery, rather than a first-come, first-served 
method or more complicated attempts to set up 
"citizen" selection groups. 

The second point I want to emphasize in these 
remarks is that we are finally beginning to face the fact 
that for some health care problems there are no final 
solutions in terms of social benefits and costs. Rather 
there are only tentative, working solutions, which 
periodically must be adjusted to changes in the itera- 
tive, continuing attempt to find the optimal socially 
acceptable coping formula. 

TECHNOLOGY'S IMPACT 

In considering the impact of technology on health 
care generally, and medicine particularly, from the 
vantage point of the U.S., it may be helpful to compare 
historical developments in that country with develop- 
ments in, for example, the United Kingdom and the 
Soviet Union. After World War II the Soviet Union ap- 
peared to emphasize distribution of resources and ac- 
cess to health care services, particularly through de- 
velopment of primary health care centers and clinics, 
and training of feldschers. The United Kingdom 
emphasized upgrading the quality of care, particularly 
in district hospitals, by training first-rate consultants; 
these consultants provide secondary care services to 
support a reasonably mature general practitioner ser- 
vice, structured to deal with problems of distribution 
and access. The U.S., recognizing the essential require- 
ment of an adequate knowledge base for clinical medi- 
cine generated by the fundamental biological and 
behavioral sciences, placed its emphasis on laboratory 
research and the associated development of tertiary 
"superspecialty" services. AH three nations now 
recognize that a balanced health care system requires 
appropriate mixes of primary, family or general health 
care services; specialty, consultant or secondary care 
services; and superspecialty, or tertiary care services. 
Also, each level of care needs to have an adequate 
scientific base, and needs to be monitored with respect 
to its accomplishment of objectives. 

In the U.S., massive outpouring of funds from the 
National Institutes of Health, directed at support of 
laboratory research, training of superspecialists, and 
provision of tertiary care, resulted in the virtual demise 
of organized systems of primary care services, espe- 
cially family medicine. This, in turn, resulted in an 
uneven quality of care at the level of the community 
general hospital. University medical centers lost inter- 
est in common, early, and general manifestations of ill 
health and morbidity in the population, and focused 
their attention on uncommon, unusual, complex, or 
"interesting" problems. Use of "interesting" prob- 



lems for education and training, reflecting the 
particularized interest of the physician or investigator, 
was not necessarily best for meeting the range of 
patient needs. By concentrating attention on this rela- 
tively small proportion of the medical problems in the 
U.S. (and an even smaller proportion of the world's 
medical problems), the American health care system 
became seriously unbalanced. 

Investigators pursuing their concern with tertiary 
care problems, and encouraged by their peers in en- 
deavors to understand and modify disease processes, 
inevitably pursued technologic solutions. The pursuit 
was aided and abetted by the societal context — that is, 
the larger society, pervaded by technology and tech- 
nological solutions to societal problems (of which the 
automobile, as the major form of transportation, is the 
prime cultural factor), which provided a most suppor- 
tive environment for an emphasis on medical technol- 
ogy- 

Increasingly elaborate technologies proliferated to 
treat relatively rare diseases and chronic diseases that 
beset a small proportion of the population. These tech- 
nologies were dubbed "halfway" by Lewis Thomas be- 
cause they treat the consequences of the disease in the 
absence of full knowledge of the disease itself. Today, 
the world, including the U.S., is beginning to recognize 
an urgent need for less complex, low-cost, high-benefit 
technologies for common problems that affect many if 
not most of the people, frequently. 

Efforts in this direction necessitate that questions be 
asked about the nature of those common problems and 
the appropriateness of any current or proposed tech- 
nological development. Diagnosis and treatment of 
common problems, such as backache, chest pains and 
headache, when first encountered at the level of pri- 
mary care, may not be significantly enhanced (consid- 
ering both benefits and costs) by complex technological 
advance alone. This point can be illustrated by the pro- 
liferation of computerized axial tomography scanners in 
the U.S. The CAT scanner is a remarkable technologic 
advance that is used to detect brain tumors and that 
may be of great value in helping to diagnose head in- 
juries, strokes, and even headaches. But while such 
technology is highly valuable when used appropriately, 
there has been little organized research to develop ap- 
propriate algorithms for its use. 

To date there are only one or two randomized clinical 
trials of CAT scanners, and these studies indicate no 
impact on mortality incidence. Unless there has been 
some recent unpublished research, there seems to be 
no evidence that CAT scanners will prevent death. 

Although impact on mortality rates is an important 
criterion for assessment, it is not the only one. There is, 
after all, societal value in reassuring a patient with a 
headache that he does not have a tumor. For these pur- 
poses the question then becomes, What should be the 
extent of a nation's investment in CAT scanners? There 
is no single correct answer to this question: it is simply 



U.S. Navy Medicine 



a matter of how a nation chooses to spend its money. 
For example, the United Kingdom expects to have 
about 25 CAT scanners for its 55 million people; the 
U.S. will soon have 1,400 scanners, at a cost of about 
$650,000 each, for four times that population. 

This is a massive social investment. Moreover, when 
the epidemiological distribution of the key problem for 
which the CAT scanner is appropriate is examined, the 
imbalance seems remarkable. In a recent year, 6,300 
people died of brain tumors in the U.S., but 23 million 
persons admitted to having recurring headaches. If 
everyone who had a tumor also had a headache, the risk 
of having a brain tumor seems to be 1 in 30,000 per- 
sons. The U.S. will shortly have a capacity for providing 
an annual brain scan for 1 person for every 60 (with or 
without a headache) in the population. Clearly, the 
question is, How do you want to spend your money? 

In the case of brain tumors, usually nothing can be 
done to save the patient's life; in the case of headaches, 
most family physicians know that they are frequently 
associated with domestic quarrels, excessive alcohol 
consumption, or occupational strains. On the basis of 
good medical practice, then, simple low-cost treat- 
ments are most likely to be effective. Little of life- 
saving value can be offered to the patient by perform- 
ing another expensive test with a CAT scanner; at best, 
this use of technology is an extremely expensive form of 
reassurance. 

HEALTH CARE DECISIONMAKING 

I wonder how well prepared the medical profession is 
to deal with such rapid advances in technology, and 
with their social consequences. We have seen a tend- 
ency to look for technological "quick fixes" for compli- 
cated problems in our health care industry — and not 
without some success, such as the polio vaccine. We 
seem to have constantly looked for solutions to prob- 
lems that were "interesting," without first making sure 
we were defining the problem appropriately and taking 
into consideration ultimate social costs and benefits. 

We also keep looking for the "silver bullet": a single 
solution to a complex problem. An early "silver bullet" 
was extensive proliferation of short-term, acute-care 
hospital bed capacity. That policy initiative then was 
associated with massive investments in biomedical re- 
search (with the side effects previously noted). The 
next substantial concentration of effort was on 
expanding health manpower supply. That effort was 
followed by recent concentration on a legislative man- 
date for the health planning process. 

Now the quick fix in vogue is "TA," or technology 
assessment. The U.S., through its National Center for 
Health Services Research and Development, suggested 
in the late 1%0's that large-scale experiments needed 
to be mounted if the nation was to move towards nation- 
alization of its health services. In the area of health care 
technology, it now seems clear that not only are more 



clinical trials needed to establish efficacy, but also, be- 
fore large-scale diffusion of technological results, 
regional large-scale testing of the effectiveness and ef- 
ficiency of such technologies needs to be conducted. 

There are, in fact, the beginnings of such an attempt 
in the State of Iowa. The legislature in that state recent- 
ly amended the State Certificate-of-Need Law and 
directed the University of Iowa Hospital and Clinics to 
evaluate new, currently available medical technology as 
well as all new health services. This innovative strategy 
in Iowa will be followed very carefully by the federal 
government over the next months. As suggested ear- 
lier, however, such studies will not provide clear-cut, 
finite solutions. Social, ethical, and economic priorities 
must be carefully considered along with empirical effi- 
cacy, effectiveness, and efficiency testing results; in 
short, complex societal judgments are involved. 

The recent U.S. decision to abandon development of 
a supersonic transport is a good nonmedical example of 
this judgmental process; in this instance, a powerful 
nation, with an enormous capacity, rejected a major 
technological development based on "an assessment" 
dominated by considerations of potential social good. 
The issue of speed was given full consideration, but the 
decision was still negative. This outcome appears to 
have been achieved through the heavy involvement of 
politics, business, and society at large in the decision; 
one-track thinking — that is, the rationale of the aircraft 
industry — was not allowed to dictate policy. 

The question I would like to pose is whether or not 
our SST decision may represent a rather new generic 
class of decisionmaking emerging in the industrialized 
world relative to technology assessment and its transfer 
— including health care technology. Such a develop- 
ment could signal the end of the relatively unfettered 
societal delegation of decision choices to professional 
experts — no matter how complex the technology — that 
has characterized developed countries for so long. 

My own feeling is that decisions in health care will 
more and more be in the same class as the SST deci- 
sion. I believe this to be the case even though the crea- 
tivity and innovativeness that should characterize the 
industry in its efforts to conquer illness, to relieve pain, 
to ameliorate the handicapped, and to resist the in- 
dignities of life's afflictions seem to set health care 
apart from other technologically involved industries. 
But I also believe that since physicians are accorded a 
special status in western society, they must assume a 
special accountability for what transpires in the provi- 
sion of health services. Since physicians foster the use 
of technology, they must also lead in helping society 
guard against the abuse of technology. This means that 
physicians must learn to be effective participants in the 
emerging societal decisionmaking process, and must 
"de-learn" past habits of exclusive, unchallenged de- 
cisionmaking. 

It also seems to me that when we discuss "technol- 
ogy" activity in the health care sector, we frequently 



Volume 69, January 1978 



21 



overemphasize the hardware or mechanical aspect of 
technology and do not examine in any depth potential 
use of technologically based capabilities in a "systems" 
sense. We rather forcibly ignore the need to pay atten- 
tion to consumer responsiveness and expectations, to 
moral and ethical choices, and to society's other social 
priorities. 

Finally, I have a deep feeling that we all need to be 
cautious and not embrace too emotionally the concepts 
of technology assessment and technology transfer. We 
might be falling into the same kind of trap we fell into 
with "operations research" after World War II. Be- 
cause of its success developing radar to detect enemy 
bombers, this type of systematic thinking was believed 
to be useful in solving organizational problems in meet- 
ing social services: the world could be reduced to 
mathematical models to identify "optimal" solutions to 
problems and to define the best implementation of 
those solutions. Somehow, it has not happened. A 
similar fate could befall technology assessment, I fear, 
if we are not careful. 

To avoid this pitfall, a principal consideration in de- 
veloping and distributing technology must be to base 
our decisions on improved determination of health 
needs; this means, in turn, that we must increase our 
research on assessments of health status and perceived 
need. Improved methods of assessing the consequences 
of research itself and on ways to use resultant new tech- 
nologies must be developed. Also, these new methods 



of assessment must yield information that can be used 
in more broadly based processes of decisionmaking. 

I believe that the public has to become more involved 
in the decisionmaking process. But to help them make 
informed decisions, they must be provided with valid, 
reliable information that they can understand. 

For all these reasons, it seems necessary to call for 
closer monitoring of research, for more studies on the 
implications of research, and for evaluation of our 
methods of assessing safety and efficacy. Finally, 
government should encourage the disclosure of 
adequate information to the public. 

Advances made in the health care field since the end 
of World War II have been truly significant and have 
changed life for the better. Future advances can be ex- 
pected to bring further improvement in the quality of 
life. However, it is now time for a new perspective for 
balancing investments among different parts of the re- 
search enterprises. It is time to set national goals and 
priorities and strategies in terms of desired and ex- 
pected outcomes. It is time to reconcile advances in 
technology with the economic, moral, and social sys- 
tems in our environments. 

These remarks then, embracing economic, social, 
and ethical judgments, along with empirical research of 
various types, represent my attempt to articulate an 
initial framework for addressing the very complex prob- 
lem of the impact of modern technology on provision of 
health care services. 



Preventive Medicine 

Giardia Iambi ia 

The small (9-21 microns) parasite known as 
Giardia lamblia infects the upper portion of the 
small intestine, attaching itself to the intestinal 
mucosa by means of a modified ventral "sucking 
disc." This parasite has long been considered basi- 
cally nonpathogenic, and is often found in asymp- 
tomatic individuals. However, there now seems to be 
abundant evidence of pathogenicity of giardiasis. In 
addition to the considerable irritation caused to the 
intestinal tract by the attachment of this parasite, its 
presence may give rise to a range of problems from 
mild diarrhea, flatulence, anorexia, and abdominal 
pain to a full-blown malabsorption syndrome. 

The distribution of Giardia lamblia is worldwide, 
with socioeconomic conditions influencing its preva- 



lence. Poor sanitation, particularly inadequate water 
sanitation, tends to precipitate outbreaks of giardia- 
sis. Epidemics, although not usually seen, are a dis- 
tinct possibility. One outbreak reported during the 
1965-1966 ski season in Aspen, Colo., was ultimately 
traced to contamination of well water from leaking 
sewage pipes. Also in 1975, some 650 American and 
Scandanavian travelers returning from the Soviet 
Union were infected in a near-epidemic. 

Treatment with quinacrine hydrochloride can be 
long and involved, and there is no safe and effective 
drug prophylaxis. Control is aimed at prevention in 
the form of increased sanitary precautions. Particu- 
larly abroad, Medical Department awareness of this 
problem is essential to preventive health care. 

—Pacific Health Bulletin, No. 98, June 1977. 



U.S. Navy Medicine 



Professional 



Stomatitis Medicamentosa Associated with 
Gold Therapy for Rheumatoid Arthritis 

LT Craig Mason, DC, USN 
CAPT Richard Grisius, DC, USN 
CAPT Thomas McKean, DC, USN 



Chronic arthritis is the number one crippling dis- 
ease in the United States, affecting over 10% of the 
population and claiming 60,000 new victims each 
year. Rheumatoid arthritis, which affects five million 
Americans, is the most serious of the arthritic dis- 
eases because of its crippling potential (1). Its etiol- 
ogy is unknown and no cure has yet been developed. 

Fortunately, various modes of treatment, includ- 
ing physical therapy and systemic medications, are 
available to alleviate the symptoms of rheumatoid 
arthritis. Notable among the many drugs used to 
treat this disease are salts of the most noble metal, 
gold. Systemic gold salts, however, produce a high 
incidence of stomatitis medicamentosa. Very little 
has been reported in the dental or medical literature 
regarding the etiology, pathology, or treatment of 
these oral manifestations. 

Injection of gold salts, or chrysotherapy, has been 
used to treat joint diseases for 50 years (2). At the 
present time, chrysotherapy is an accepted mode of 
treatment for active rheumatoid arthritis. Its use is 
indicated early in the therapeutic course for patients 
who have not responded well to salicylates, heat, and 
physical therapy (3). When this criterion of patient 
selection is employed, most patients experience a 
decrease in acute inflammatory signs and symptoms, 
and the progress of the disease may be retarded, as 
evidenced radiographically (4). 



From the Dental Service of the Naval Regional Medical Center, 
Oakland, Calif. 94627. 

This study was supported in part through funds provided by 
the Bureau of Medicine and Surgery, Navy Department, for CR 
48-8-10. 



Sodium aurothiomalate and sodium aurothioglu- 
cose are the most commonly used gold salts. After 
several small challenge doses, weekly injections of 
50 mg of gold are administered up to a total of 
0.8-1.5 gm gold or until toxic reactions occur. If the 
therapy has been successful in producing remission, 
maintenance injections of 50 mg gold every two to 
four weeks may be administered indefinitely (3,5). 

How gold acts to alter the course of rheumatoid 
arthritis is not yet fully understood. When admin- 
istered intramuscularly in aqueous preparations, the 
salts are rapidly absorbed. Gold is deposited in cells 
of the reticuloendothelial system and is concentrated 
in inflamed tissues, notably in inflamed synovial 
membranes . Clinically painful joints are reported to 
concentrate 2.5 times more gold than asymptomatic 
joints (5,6). While there is strong evidence that toxic 
reactions to gold salts are mediated immunologically 
( 7-9) , several studies have concluded that gold does 
not influence the course of rheumatoid arthritis by 
any action upon the immune response (10,11). 

It has been demonstrated that gold is concentrated 
in the lysosomes of phagocytic cells, notably macro- 
phages, and that it inhibits lysosomal hydrolases 
(12). Mycoplasma organisms have been indicated as 
possible etiologic agents in rheumatoid arthritis (13); 
animal studies have shown gold to suppress these 
organisms and the arthritic lesions they cause (14) . It 
also has been reported that the stability of collagen 
increases in the presence of gold (15). 

The main objection to the use of chrysotherapy is 
the accompany toxic reactions reported to occur in 
32 % of patients at the presently accepted therapeu- 
tic dose regimen (3). The most common toxic 



Volume 69, January 1978 



reactions are dermatitis and stomatitis, which are 
rarely debilitating. A significant number of patients, 
however, do develop severe complications, including 
nephrotic syndrome, hepatitis, thrombocytopenia, 
agranulocytosis, and aplastic anemia. Severe toxic 
reactions call for immediate cessation of therapy, 
while minor complications may be overcome by a 
reduction of dosage or by omitting one or several 
injections. There does not appear to be any well- 
defined relationship between the occurrence of toxic 
reactions and the success of therapy at producing 
remission in individual patients {16}. 

Stomatitis resulting from chrysotherapy can occur 
on the lips, gingiva, tongue, palate, or buccal 
mucosa and is sometimes accompanied or preceded 
by a metallic taste. The reported incidence is ex- 
tremely variable, ranging from 5% to more than 
60% (17,18). In studies of patients receiving weekly 
dosage of more than 50 mg gold, stomatitis occurred 
significantly more often than when 50 mg or less 
gold was administered weekly {19). Aqueous prepa- 
rations apparently produce a greater incidence of 
stomatitis than oily suspensions (18). 

The reported severity of stomatitis ranges from 
localized erythema and tenderness to ulceration or 
desquamation of large areas of mucosa, accom- 
panied by severe pain and dysphasia {19). Symptoms 
may resolve in a short time with or without cessation 
of chrysotherapy, or they may run a protracted 
course of many months as was true with the patient 
described below. 

PATIENT REPORT 

In June 1976, a 21-year-old Caucasian female was referred 
from the Rheumatology Clinic to the Dental Service at Naval 
Regional Medical Center Oakland, Calif., for evaluation and 
treatment of oral symptoms. 

The patient had been diagnosed in August 1975 as having 
classic rheumatoid arthritis. After unsuccessful courses of 
therapy with salicylates and ibuprofen, chrysotherapy was begun 
in November 1975. Following challenge doses of 10, 25, and 35 
mg gold on successive weeks, 50 mg per week of gold in the form 
of sodium aurothiomalate was administered by deep intramuscu- 
lar injection. After she received 1 gm of gold, the patient was in 
nearly complete remission. Maintenance therapy consisting of 50 
mg sodium aurothiomalate monthly was begun. 

Six weeks before she was seen in the Dental Service, the pa- 
tient had her ears pierced and began wearing 14-karat gold 
ear-posts. Two days later, serous drainage began from the ear 
lobes and three weeks later a pruritic urticarial eruption ap- 
peared. This eruption began Eve days after gold salts were 
injected on the skin of the ears and mastoid areas; within 72 
hours the eruption involved the patient's neck, back, and upper 
chest. The gold ear-posts were removed and the patient was 
treated with systemic triamcinolone acetonide and diphenylhy- 
dramine hydrochloride. The rash resolved in four days; chryso- 
therapy was not interrupted. 



The patient presented to the Dental Clinic in June 1976 with a 
chief complaint of discomfort of several months duration in the 
maxillary anterior area and mandibular left posterior area. The 
patient said that the pain was severe and accompanied by spon- 
taneous bleeding on the days of gold injections and the first few 
days immediately following. 

Examination in the Dental Clinic revealed pericoronitis around 
a partially erupted mandibular left third molar, and diffuse gen- 
eralized severe gingivitis with gross accumulations of plaque and 
calculus. For four years the patient had been successfully wear- 
ing a gold alloy removable partial denture which replaced the 
maxillary left central incisor and the right cuspid and central and 
lateral incisor teeth. The palatal mucosal beneath the removable 
partial denture exhibited some papillary hyperplasia, was fiery 
red, and bled with minimal stimulation. 

The gingivitis was treated with an initial scaling of the teeth 
and plaque control instructions followed by plaque removal at 
two-week intervals. The pericoronitis was treated by extracting 
the third molar teeth and administering systemic phenoxymethyl- 
penicillin. At the end of two months the gingivitis was markedly 
reduced, but the palatal mucosa underlying the removable partial 
denture remained inflamed and tender. At that time it was 
elected to replace the gold alloy partial denture with an acrylic 
resin prosthesis as a diagnostic aid. 

During the next sue months the palatal inflammation improved 
but portions of the mucosa remained red and tender, becoming 
more symptomatic on and immediately following days when gold 
injections were given. The involved mucosa bore no relationship 
to the tissue covered by the new prosthesis, but rather corre- 
sponded to the area previously in intimate contact with the gold 
alloy denture base. 

Upon consultation, the Dermatology Department performed 
standard 48-hour patch tests with 24-karat gold foil, metal from 
the patient's gold alloy removable partial denture framework, 
chromium, nickel, and cobalt, as well as intradermal testing with 
sodium aurothiomalate. The results were negative. 

Following these tests, a removable partial denture with cast 
nickel-chrome framework and acrylic resin denture base was 
constructed. The patient tolerated this denture well. 

One year after her initial examination in the Dental Service, the 
patient is continuing on maintenance chrysotherapy and her 
rheumatoid arthritis remains in remission. The mucosa previ- 
ously covered by the gold denture base remains mildly inflamed 
and becomes symptomatic on days of monthly injections and im- 
mediately following. 

DISCUSSION 

Stomatitis and dermatitis medicamentosa are the 
two most common toxic reactions to chrysotherapy, 
and appear to be hypersensitivity reactions mediated 
by the immune response {7-9). In the patient dis- 
cussed in this report, oral and dermal reactions both 
occurred in tissues which were in intimate contact 
with metallic gold alloys— raising the question of 
possible sensitization by contact with metallic gold or 
other metals contained in the alloys. Negative patch 
and intradermal tests, however, make the diagnosis 
of classic allergic response unlikely. The pattern of 
increased mucosal inflammation on days of and 
following injections indicates a fixed drug eruption. 



24 



U.S. Navy Medicine 



Many patients report increased pain and stiffness 
in affected joints shortly following gold injections. 
These focal reactions usually subside within a few 
days and cease to occur as the disease comes under 
control. 

These symptoms have been attributed to the rapid 
accumulation of gold in the inflamed tissues of the 
affected joints. Theoretically, such a concentration of 
gold should occur in any inflamed tissue, which 
might explain the increased oral signs and symptoms 
seen in our patient on days of and following injec- 
tions. 

Gold is eliminated from the body very slowly, with 
traces present in the urine more than a year 
following administration (20). For this reason we 
anticipate that our patient's signs and symptoms will 
persist well beyond the eventual cessation of chryso- 
therapy. 

REFERENCES 

1. Arthritis— The Basic Facts. New York: The Arthritis Foun- 
dation, 1976, p 2. 

2. Henneberg Z, Rozanic V: New aspects of aurotherapy. 
Lijec Vjesn 90:885-888, 1968. 

3. Myers A: Chrysotherapy in rheumatoid arthritis. Modern 
Treatment 8:761-768, 1971. 

4. Sigler JW, Bluhm GB, Duncan H, et al; Gold salts in the 
treatment of rheumatoid arthritis. A double-blind study. Ann In- 
tern Med 80:21-26, 1974. 

5. Davison S: Treatment of rheumatoid arthritis with gold, 
Mt Sinai J Med NY 41:807-811, 1974. 

6. Lawrence JS: Studies with radioactive gold. Ann Rheum 
Dis 20:341-352, 1961. 

7. Louyot P, Grilliat JP, Monneret-Vautrin D, et al: An im- 



munological study of intolerance to chrysotherapy using Shelley's 
test, the lymphoblastic transformation test (TTL), and the inhibi- 
tion of leucocyte migration test (TTML). Rev Rhu Mai Osteoartic 
41:1-9, 1974. 

8. Davis P, Hughes GRV: A serial study of eosinophilia and 
raised IgE antibodies during gold therapy. Ann Rheum Dis 34: 
203-204, 1975. 

9. Denman EJ, Demnan AM: The lymphocyte transformation 
test and gold hypersensitivity. Ann Rheum Dis 27:582-589, 1968. 

10. Persellin RH, Hess EV, Ziff M: Effect of a gold salt on the 
immune response. Arthritis Rheum 10:99-106, 1967. 

11. Huskisson EC, Berry H: Some immunological changes in 
rheumatoid arthritis among patients receiving penicillamine and 
gold. Postgrad Med J 50{supp 2):59-61, 1974. 

12. Persellin RH, Ziff M: The effect of gold salt on lysosomal 
enzymes of the peritoneal macrophage. Arthritis Rheum 9:57-65, 
1966. 

13. Bartholomew LE: Isolation and characterization of myco- 
plasmas (PPLO) from patients with rheumatoid arthritis, 
systemic lupus erythematosus and Reiter's syndrome. Arthritis 
Rheum 8:376-388, 1965. 

14. Marion BP, Goodburn GM: Effect of an organic gold salt 
on Eaton's primary atypical pneumonia agent and other observa- 
tions. Nature 189:247-248, 1961. 

15. Adam M, Bartl P, Deyl Z, et al: Uptake of gold by collagen 
in gold therapy. Ann Rheum Dis 24:378-381, 1965. 

16. Relation of toxic reactions in gold therapy to improvement 
in rheumatoid arthritis. The Research Subcommittee of the 
Empire Rheumatism Council. Ann Rheum Dis 20:335-340, 1961. 

17. Hartfall SJ, Garland HG, Goldie W, et al: Gold treatment 
of arthritis: review of 900 cases. Lancet 2:784, 838-842, 1937. 

18. Lawrence JS: Comparative toxicity of gold preparations in 
treatment of rheumatoid arthritis. Ann Rheum Dis 35:171-173, 
1976. 

19. Lawrence JS: Factors in gold dosage and toxicity in rheu- 
matoid arthritis. Ann Rheum Dis 12:129-135, 1953. 

20. Freyberg RH: Gold salts in treatment of chronic arthritis: 
metabolic and clinical studies. Proc Staff Meet Mayo Clin 17:534- 
541, 1942. 



Occupational Health 



Eliminating Cadmium Hazards 



NAVSEA Notice 9074 of 16 May 
1977, "Cadmium plating and mate- 
rials containing cadmium, elimina- 
tion of requirements for in selected 
applications," outlines the hazard 
of cadmium as used throughout the 
Navy. The high level of toxicity is 
cited as reason for eliminating its 
use. Where substitute materials are 
approved or available, their use is 
encouraged. 

Specifically, Naval Ships Techni- 
cal Manual, chapter 075, of 1 Nov 
1976 prohibits use of cadmium- 



plated fasteners, including washers 
used at temperatures above 205° C 
(400° F) or in contact with fuel, 
grease, lubricating oil, or oil-based 
hydraulic fluids. When possible, 
cadmium-containing products shall 
not be used in brazing operations. 
Ventilation requirements of Naval 
Ships Technical Manual, chapter 
9920, section 264, should be com- 
plied with for all brazing operations, 
particularly those using cadmium. 

Brazing of cadmium shall not be 
permitted unless the fumes can be 



exhausted to the atmosphere. Per- 
sonnel who handle cadmium-coated 
or cadmium-containing materials 
should wash their hands before eat- 
ing or smoking. 

A list of cadmium-free silver 
brazing alloys, prepared by the U.S. 
Army Environmental Hygiene 
Agency, is available from the Navy 
Environmental Health Center 
(Attn: Cindy Ingalls, Code 4201), 
3333 Vine St., Cincinnati, Ohio 
45220. A list of cadmium- containing 
alloys is also available. 



Volume 69, January 1978 



25 



Outpatient Medical Records Audit 



CDR Leslie C. Eilwood, MC, USN 



Audit of outpatient medical records is generally 
reviewed pessimistically (1,2), although the desir- 
ability of such action is obvious. Among the prob- 
lems encountered in attempts to audit the medical 
records of outpatient practices are: 

• lack of accepted criteria of care . 

• inadequate recording of care delivered by physi- 
cians. 

• difficulty retrieving data, because outpatient 
records are not coded for diagnosis. 

Within the military health care system, however, 
none of these problems is insurmountable. If we 
adhere to the idea of local programs "developed, 
implemented, and monitored by the local staff clini- 
cians" (3), effective outpatient medical care evalua- 
tion programs can be set up. 

In the pediatric outpatient clinic of ADM Joel T. 
Boone Clinic in Norfolk, we instituted a process audit 
using explicit criteria for the care of otitis media 
(2, 4) . Through this audit we were able to document 
the quality of our medical care, provide an educa- 
tional experience for our pediatric staff, and 
generate data useful in organizing clinic services. 

PROCESS AUDIT 

A process audit, as defined in the Performance 
Evaluation Procedures of the Joint Committee on the 
Accreditation of Hospitals (4) , is used to determine 
whether medical management of a specific illness or 
problem is appropriate. This is in contrast to the 
usual inpatient medical audit which is oriented to 
treatment outcome. The principal purpose of our 
process audit at Boone Clinic was to develop criteria 
for care of acute otitis media, with particular atten- 
tion to physician's notes justifying the diagnosis, 
medication prescribed, follow-up documentation, 



and critical medical management of common compli- 
cations. 

After basic instruction in the structure and method 
of medical record audits, and after a 90-minute dis- 
cussion among the clinic's pediatricians, we devel- 
oped our audit for otitis media. Each clinician was 
given a copy of the audit worksheet (Figure 1) and 
told that the individual items of care had to be re- 
corded in the patient's health record for an audit ele- 
ment to be considered complete. The pre-audit 
instruction sheet carried a consensus list of terminol- 
ogy which would satisfy elements la and lb, and 
appropriate antibiotic dosages for element 3. Thus 
criteria of acceptable care and terminology were 
established by staff consensus and the need to 
record care properly was reinforced. A sample chart 
entry adequate to satisfy all audit elements is shown 
in Figure 2. 

It was relatively easy for us to retrieve the charts 
of patients with acute otitis media because of the 
clinic's appointment system for repeat ear examina- 
tions. The names of children returning for reexami- 
nation following a clinic visit for acute otitis media, 
as well as the social security numbers of the chil- 
dren's sponsors, were selected at random. All chart 
entries pertaining to treatment or followup of these 
patients' otitis media over a 2 Vi -month period were 
evaluated for adherence to audit elements as explic- 
itly recorded by clinic physicians. Other statistical 
data were also recorded. 

We ensured anonymity by using a code number 
for each physician on all audit worksheets and re- 
ports. After the clinic staff reviewed and discussed 
the findings of the completed audit, we told each 
physician what his or her audit number was. 

RESULTS 



From the Pediatrics Clinic, ADM Joel T. Boone Clinic, Little 
Creek Amphibious Base, Norfolk, Va. 23520. 



Two hundred and four outpatient records were 
audited from 244 records originally selected. Thirty- 
three (13.5%) of the original charts were assumed 



26 



U.S. Navy Medicine 



FIGURE 1. Outpatient Process Audit for Acute Otitis Media 



Elements Standard 


Exceptions 




Elements ! 


Standard 


Exceptions 


Justification for Diagnosis 


. 






Recurrence noted: 






1 . Examination must 


100% 






7. > 2 acute otitis in 


100% 




reveal both: 








preceding 3 months 






a. Evidence of sub- 








noted by physician 






stance other than 














air behind tym- 








Folio wup; 






panic membrane 








8. Final followup exam 


100% 


Final chart entry meets 


b. Evidence of in- 








for acute otitis media 




critical management for 


flammation 








episode reveals nor- 




complication, or ENT 


Therapy: 








mal ear by otoscopy 




referral completed. 


2. Requires antibiotics 


100% 






Complications: 




Critical management: 


3. Prescribed antibiotic £ 


100% 






1. Serous otitis media 


0% 


1. Decongestant, follow- 


minimum recom- 












up scheduled. 


mended dosage. 








2. Persistence of infec- 


0% 


2. Antibiotics. (Note 


4. Dosage schedule of 


100% 






tion 




indicates probable com- 


antibiotic at least t.E.d. 












pliance with initial ther- 


5. Medication pre- 


100% 










apy; followup sched- 


scribed for at least 












uled). 


7 days 








3. Perforation 


0% 


3. Followup scheduled. 


6. Antibiotic spectrum 


100% 


Therapy is for persist- 


4. Allergic reaction to 


0% 


4. Noted; antibiotic dis- 


H. influenza when 




ence of otitis, and 


initial 


antibiotic 




continued. 


child < 4 years 




therapy covers H. 
ertza. 


influ- 


5. Severe diarrhea 


0% 


5. Noted for future anti- 
biotic choice. 



not to be in the files after they could not be found on 
three different days. Seven charts had diagnoses 
other than middle ear disease. 

The 204 charts audited contained approximately 
500 individual entries. 

The need for complete recordkeeping within our 
outpatient military clinic was readily apparent when 
we found that in 108 charts (51.8%), two or more 
physicians had cared for a patient (original diagnosis 
and followup examinations) in the course of one 
episode of otitis media. Only 48 % of the patients saw 
the same physician for care of their acute problem as 
well as followup. The number of charts for which 
each physician was audited ranged from 16 to 37. 
Since more than one physician made entries in some 
52% of charts, our review of these charts was re- 
corded as a chart audit for each physician involved in 
the patient's care. 

We also recorded how often and in what way phy- 
sicians varied from the established audit, noting 
when each physician failed to record an element. 
These variances indicated only errors in medical 
record entry, not necessarily errors in medical prac- 
tice. 

The most common error was recorded for element 



FIGURE 2. Sampleof Adequate Chart Entry 
Using SOAP System* 



12 Nov 1976 S: 2-year-old male with history of otitis media 
Wt:28lbs in early October, normal ears on 27 Oct; 

now has cold, fever, and right earache. 

O: Right ear is red and bulging with yellow 
fluid. Left ear is normal. 
Nose has clear rhinorrhea; throat benign. 
Lungs clear. 

A: Right otitis media 

P: Ampicillin 250 mg t.i.d. x 10 days. 
Sudafed 1 tsp t.i.d. 
Recheck ear in 2 weeks. Signature M. D. 

*The SOAP system of chart entries is taught in many medical 
schools and residencies. It ensures that the following informa- 
tion is recorded: 

S = SUBJECTIVE = History = Illness as described by pa- 
tient. 
O = OBJECTIVE = Physical exam = Signs and physical 

findings as noted by physician. 
A = ASSESSMENT = Impression = Physician's diagnosis. 
P = PLAN = Disposition = Treatment plan, including medi- 
cation, counseling, and followup. 



Volume 69, January 1978 



27 



5, in which the physician must indicate duration of 
therapy. Some 54 chart entries failed to give this in- 
formation. 

The second most common error was failure to 
record patient compliance with prescribed antibiotic 
regimen when persistent otitis media was noted in 
followup exam. This error occurred in 13 of 49 chart 
entries describing persistent otitis media. Such 
information would be important for physicians 
choosing an antibiotic as the second therapy: for 
example, they would need to know whether the 
dosage was inadequate or the organism not sensi- 
tive. In 11 entries we could not determine the milli- 
gram dosage of antibiotic prescribed, and in 5 chart 
entries the dosage schedule was not recorded. 

There were only four errors noted in which the 
diagnosis of infected eardrum failed to describe both 
middle ear fluid and inflammation. There were no 
errors in use of the appropriate antibiotic spectrum 
for age group. All records indicated that physicians 
had reviewed other chart entries while caring for 
children with chronic otitis media. 

The total number of errors was 89. If in 204 charts, 
each requiring completion of 14 elements, there are 
possible 2,856 errors, then these 89 errors represent 
an error rate of 3.17%. A medical record audit in 
which the physicians were not aware of the required 
elements while recording patient care would 
probably yield a much higher error rate. However, 
the purpose of an audit need not be retrospective 
identification of physician errors. Rather, a charts 
audit, such as this one, can be an educational tool: 
physicians first decide upon the best recordkeeping 
elements, then practice fulfilling these elements 
while the audit is in progress . A continued series of 
outpatient audits on varied diagnoses will reinforce 
good recordkeeping in all areas . 

Also, as was true in our experience, additional 
data obtained during the audit can be valuable in 
organizing clinic services. As an example, serous 
otitis media following acute otitis media was noted in 
80 charts (39.2%), with 101 entries for serous otitis 
media recorded, since this problem was diagnosed in 
some patients on more than one visit. Persistent 
fluid and inflammation after antibiotic therapy were 
recorded in 44 charts (21.5%), with 49 episodes of 
apparently persistent infection. Such data indicated 
it is desirable that all children with otitis media have 
their ears reexamined after they complete prescribed 
medication. Such data could also be used to estimate 
the number of appointments a clinic will have to 
reserve for ear reexaminations. 

Of the 204 reexaminations initially scheduled after 



a diagnosis of acute otitis media, there were 101 in- 
stances of serous otitis media and 49 instances of 
persistent inflammatory otitis media requiring 
further examination. Thus a total of 354 visits were 
generated from 204 first followup visits scheduled— 
a ratio of 1 acute otitis visit to 1.7 reexamination 
visits. The number of appointments lost because pa- 
tients failed to appear was 24 (12.3%). 

In hours, the audit "cost" us 29 physician-auditor 
hours, 3 hours for pediatric staff meetings, and 3 
hours medical records personnel spent retrieving 
charts. 

Patient care evaluation has been mandated by the 
Federal Government under Professional Standards 
Review Organization legislation, by health insurance 
carriers eager to reduce hospitalization costs , and by 
the Joint Commission on Accreditation of Hospitals. 
Also, as U.S. Medicine noted in its 1 Nov 1976 issue, 
"complete and proper entries" in military medical 
records are essential to the defense of medical 
malpractice suits that might be brought against the 
Navy. 

Military clinics— essentially large group practices 
with fairly uniform methods, central record files, and 
centralized administrative functions— have advan- 
tages over the type of individual practice where out- 
patient audits have so far proved unsatisfactory. 

Our chief problem— random selection and retriev- 
al of charts of patients with a specific diagnosis— can 
be overcome if sufficient ingenuity is applied. For 
example, a clinic could keep lists of patients who 
request refills of diagnosis-specific medication like 
antihypertensive drugs, birth control pills, or Ritalin. 
Or lists could be kept of patients whose laboratory 
tests are returned to the clinic showing positive urine 
cultures or pap smears. Lists could also be made of 
names taken from appointment cards for clinics that 
treat only specific illnesses. If the scope remains 
reasonably limited, the time required for the audit 
would not deter any physician, nurse, or hospital 
corpsman who desires to improve our health care 
system. 

REFERENCES 

1. Osborne C, Thompson H: Criteria for evaluation of ambu- 
latory child health care by chart audit: development and testing 
of a methodology. Pediatrics 56{suppl 4|:625-29, 1975. 

2. Mead W: Quality assurance for health supervision of the 
ambulatory child. J Fam Pract 3(6):587-91, 1976. 

3. Custis D: Medical care evaluation programs. US Nav Med 
67(6):1, 1976. 

4. Jacobs CM, Jacobs NP: Performance evaluation proce- 
dures for auditing and improving patient care, in PEP Primer. 
Chicago: Joint Commission on Accreditation of Hospitals, 1975. 



28 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Physical Exam 
Before ACDUTRA 



Some confusion persists concerning the physical ex- 
amination that is required before you report for each 
period of active duty for training (ACDUTRA). The 
exam is required regardless of whether ACDUTRA is to 
be performed at your school or at a naval activity. 

Because the naval activities that perform these physi- 
cal examinations usually cannot respond to last minute 
requests, you should arrange for your physical exam as 
soon as you receive ACDUTRA orders. If you have al- 
ready had a complete physical examination within 12 
months of the reporting date on your ACDUTRA 
orders, you don't have to get another one provided 
Standard Form 88 and Standard Form 93 from your last 
physical exam are still filed in your health record. But 
you must still report to a naval or Naval Reserve facility 
so a Medical Department representative (usually a 
medical officer) can ascertain that there has been no 
significant change in your condition and that you con- 
tinue to be physically qualified for active duty. Your 
physical fitness will be certified by an entry on Stand- 
ard Form 600 as well as on your ACDUTRA orders. 

Try to obtain a signed copy of SF 88 and SF 93 each 
time you complete a physical examination, so you can 
take advantage of the 12-month provision whenever it 
applies. 

Gl Bill Education 

Armed Forces Health Professions Scholarship stu- 
dents who were on active-duty for 180 consecutive days 
or more on or prior to 31 Dec 1976 may be eligible for 
benefits under the Veterans Education and Employ- 
ment Assistance Act of 1976. Monthly payments are 
$292 for full-time students with no dependents, $347 
with one dependent, $396 with two dependents, plus 
another $24 for each additional dependent. Interested 
students should check with the nearest VA office to 
determine their eligibility. 

Students in the Navy Medical and Osteopathic 
Scholarship Program and the Navy Dental Scholarship 
Program are not eligible for VA inservice educational 
benefits if their tuition is paid by the Navy. However, 
educational benefits may be provided when tuition is 
not paid by the Navy, such as during vacation makeup 
courses not covered by the scholarship program. 



Scholarship Student 
Reimbursement Claims 



All reimbursement claims are forwarded to the Naval 
Regional Finance Center, Washington, D.C., for pay- 
ment. It takes from four to six weeks to process these 
claims. But it takes even longer when the last copies of 
the multiple-copy claim forms are not eligible; NRFC 
employees must then spend extra time at the copy 
machine — a considerable chore when several hundred 
claims are involved. You can help them by making sure 
all copies of the claims form can be read. You'll help 
yourself, too: the Naval Health Sciences Education and 
Training Command is now returning claims when the 
last copies are not legible. 



HE KNOWS THE ROPES 



When we say someone knows the ropes we infer that 
he knows his way around at sea and is quite capable of 
handling most nautical problems. Through the years the 
phrase's meaning has changed somewhat. Originally, the 
statement was printed on a seaman's discharge to indi- 
cate that he knew the names and primary uses of the 
main ropes on board ship. In other words, "This man is 
a novice seaman and knows only the basics of seaman- 
ship." 




Volume 69, January 1978 



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